Director of CR-RISQ

Job Summary:
The director is responsible for developing, implementing, and monitoring the quality improvement (QI), risk management (RM), infection prevention & control (IPC), and TJC readiness programs in the hospital. Additionally, the director monitors and ensures compliance with all regulations and laws pertaining to the facilities operations. This overall objective of the director is to institute systems and monitors to maximize the quality of care and maintain high levels of safety. The director reduces risks or eliminates hazards that could cause an injury and result in litigation for the facility. Serves as the accreditation liaison. Coordinates accreditation preparation and activities.

Duties:
*All duties listed below are essential unless noted otherwise*

• Solicits staff suggestions for improving patient safety with a commitment to openly listen to staff concerns/suggestions about patient care. Communicate with staff to promote a non-punitive environment where staff feels they can openly voice concerns.
• Reviews maintenance/repair reports of electrically powered patient care equipment and provides adequate follow-up on any found deficiencies.
• Initiates corrective action in response to safety surveillance findings to include equipment repair/adjustment and employee educational events.
• Communicates verbally and/or in writing to appropriate hospital/department staff regarding issues.
• Conducts departmental education based on quality improvements/safety surveillance findings and department needs.
• Maintains safety/operational instructions for all appropriate department equipment. Assures early access of instructions for clinical staff.
• Maintains current knowledge on safety issues involving personal protective equipment and supplies used in respective area.
• Ensures appropriate and timely completion of and follow through of employee incident reports, including investigations.
• Carries out department specific safety orientation for new employees.
• Completes mandatory safety requirements.
• Follows safety/Infection Control Policies
• Demonstrates adherence to safety policies fifi evidenced by leadership and employee practices.
• Maintains a clean and safe environment for patients and coworkers.
• Follows all general safety rules.
• Identifies the person designated as Patient Safety Officer.
• Demonstrates and understanding of fire drills, internal/external disaster plans and procedures, and evacuation procedures as evidenced by Inservice records and participation in drills.
• Demonstrates knowledge of safety committee activities.
• Maintains confidentiality regarding knowledge of adverse incidents.
• Has improved or maintained department performance in the following areas:
• Central venous catheter related bloodstream infections
• Complications associated with ventilator use.
• Catheter associated urinary tract infections
• Developing VTE, and subsequent pulmonary embolism
• Quality of the informed consent process for all patients
• Performing unwanted life-sustaining treatment or withholding resuscitation
• Timely and understandable communication of patient care information to the patient and his/her care providers
• Adverse events resulting from non-standardized, fragmented or ineffective information transfer at time of discharge
• Adverse drug events and the medication reconciliation process
• Hospital-acquired infections related to inadequate hand hygiene
• Any other process or procedure related event where there is a potential for an adverse outcome
• Coordinates and oversees organization-wide performance improvement activities:
• Develops, implements, and annually reviews the facility performance improvement plan with the hospital senior leadership team, Commit to Quality Committee, and Medical Executive Committee.
• Develops and presents an annual performance improvement activity report.
• Reviews and revises the performance improvement plan with assistance of the Commit to Quality Committee, and Medical Executive Committees.
• Works with department leaders, hospital senior leadership, medical staff, Commit to Quality to ensure performance improvement activities are carried out. Communicates status to all stake holders within the organization.
• Works with ICU and respiratory leaders to improve ventilator care and reduce incidence of ventilator associated pneumonia.
• Coordinates the completion of required reviews (i.e., blood utilization, surgical case review, deaths, etc.), reporting to committees as indicated.
• Coordinates infection control surveil lance activities. Works with the chair of the Infection Control Committee to ensure activities are within IPC standards and movement toward compliance in Infection Prevention & Control.
• Oversees and ensures Michigan benchmarks are reached regarding core measures, keystone activities, pay for performance, and regulatory compliance.
• Serves as chair of the Commit to Quality Committee
• Presents quality information at medical committees, CQC, and department meetings.
• Serves as accreditation liaison. Coordinates accreditation preparation and activities.
• Ensures facility-wide understanding of and compliance with JC and CMS standards.
• Provides training/consultation to departments, medical staff and board members as needed.
• Assists in coordination of educational needs of all levels of staff related to RM, IPC, TJC, QI and core measures, pay for performance, and CMS regulation compliance.
• Establishes criteria for data to be collected and facilitates review by section chiefs and promotes case review.
• Prepares medical staff quality improvement report that documents performance improvement issues studied, actions/recommendations and follow-up.
• Oversees the patient experience department and functions.
• Assists with patient, family, visitor concerns/complaints, when needed.
• Trends and analyzes concerns. Completes annual staff safety perceptions surveys and develops action plans with department leaders to move forward.
• Consults with departments with goal of improving their performance in terms of performance improvement/lean projects, utilization, and risk management.
• Assists in training staff in matters related to PI/RM, lean concepts.
• Praises performance improvement soon after it occurs.
• Provides the materials and equipment employees need to do the job right; eliminates barriers.
• Works with staff to prioritize and plan their work to meet assigned objectives.
• When a supervisee's performance is inadequate in an area, formally provides notice of concern and takes corrective action to structure his or her development.
• Explicitly discusses performance standards with a supervisee before being critical of job performance.
• Formally reviews and appraises the performance of supervisees.
• Facilitates the resolution of problems and conflicts (encourages decision making by those responsible, remains objective, respects feelings, draws out advantages and disadvantages to each idea).
• Assists in development of job description and quickly updates it when expectations arc changed.
• Helps each supervisee design an individual development plan, as appropriate, and then monitors the plan to ensure progress.
• Delegates tasks and shares responsibility and authority whenever appropriate.
• Oversees hospital claims management in conjunction with corporate legal counsel office:
• Maintains an occurrence reporting system.
• Analyzes events for claims potential.
• Manages claims program and is active in coordination of peer review process, ensuring regulatory compliance in these areas.
• Reviews risk management program annually and revises as necessary.
• File Maintenance & Reporting RM Activities:
• Coordinates risk management activities with the insurance carriers and legal counsel.
• Maintains risk management statistics and confidential files.
• Tracks and trends risk management data and prepares reports.
• Presents annual risk management reports.
• Maintains and Provides Risk Management Education:
• Develops, coordinates and provides for risk management education programs to facility departments, medical staff and Board of Trustees.
• Maintains education in risk management through attendance at seminars/conferences and membership in professional organizations.
• Oversees the organization and coordination of the work of the department and coordinates same with that of other units/departments.
• Institutes and enforces necessary unit/department policies and guidelines.
• Assists the staff to understand and be committed to organizational policies and management decisions.
• Addresses and resolves outside complaints about employee or unit's/department's activities.
• Seeks out and applies new professional and technical concepts.
• Provides reports, as necessary, that substantiate the unit's/department's activities.
• Fosters positive relationships with employees, patients, Medical Staff and referral sources.
• Arranges for or provides training to maintain and enhance staff competency on an annual basis.
• Provides, as necessary, short and long-term plans that support the mission, values, goals, and objectives of the hospital.
• Other duties as assigned.

Required Qualifications:
Education: Bachelor's degree in nursing or related field, or equivalent experience. Must be enrolled in health-related master's degree program (MSN, MHA, etc.) within 6 months of hire and must complete program within 2-3 years after enrollment.
Skills: Word, Excel, PowerPoint, RL6
Years of Experience: 3+ years of equivalent experience
License: RN or other healthcare related license/registration
Certification: N/A

Preferred Qualifications:
Education: Master's degree in healthcare related field (MSN, MHA, etc.).
Skills: Lean process, Six Sigma, or other process improvement program
Years of Experience: 5+ years of experience in risk management or hospital quality improvement.
License: RN or other healthcare related license/registration
Certification: Certification in risk management or hospital quality improvement

Working Conditions:
Environment: Work is primarily performed in a healthcare setting, including administrative
offices, patient care units, and clinical environments. Frequent interaction with hospital staff,
leadership, regulatory agencies, and patients/families may be required.
Physical Requirements: May involve long periods of sitting, standing, and walking throughout
the hospital campus. Occasional lifting of up to 25 pounds may be required (e.g., transporting
reports or training materials).
Other Requirements: May require use of personal protective equipment (PPE) when entering
clinical areas. May require travel to off-site clinical offices.
Technology: Regular use of computers, electronic health records (EHR), incident reporting
systems, and regulatory compliance databases.