FTE: 8:00am - 4:30pm - GENERAL SUMMARY The Director of Quality, Risk and Patient Safety are responsible for the design, development, implementation, evaluation, and continuous improvement of the hospital-wide quality and patient safety system, accreditation/regulatory readiness and clinical informatics.
DESCRIPTION 1.Develops and oversees implementation and management of the patient safety program. Designs and implements a system and process to improve the culture of safety and reduce risk of harm to patients. - Designs and implements a system and process to improve the culture of safety and reduce risk of harm to patients.
- Oversee the implementation and management of patient safety event reporting.
- Reviews patient safety events (includes near misses) using root cause analysis methodology to identify where system problems exist, and collaborates with staff, leaders and physicians on developing and implementing corrective actions that will reduce harm to patients.
- Monitors incidents placed in the reporting system to identify safety trends and react to the trends by facilitating improvements using quality improvement methodology.
- Designs and implements systems to communicate patient safety events.
- Develops, in collaboration with leaders, patient safety metrics that are in line with reducing patient harm.
- Leads hospital-wide efforts to educate staff and physicians on Culture of Safety.
- Maintains knowledge of the latest national developments in patient safety.
2. Develops and oversees implementation and management of the quality management/performance improvement program to assure planned, systematic and ongoing processes for monitoring, evaluating, and improving the quality of care and safety of patients. - Oversees the hospital Quality and Safety Committee
- Serves as a consultant to leadership, medical staff and other care providers to define quality measures, data collection and quality improvement efforts.
- Develops, modifies and maintains the hospital's quality and safety plan.
- Oversees the hospitals Stroke and Sepsis programs.
- Ensures value based purchasing and other regulatory reporting of quality and safety measures for inpatient and outpatient services.
- Participates in various hospital committees.
- Leads hospital-wide efforts to educate staff on quality improvement methodology.
3. Leads the hospital to be in a constant state of continuous survey readiness. - Remains up-to-date on all federal / local regulations and accreditation standards.
- Prepares staff, leaders, and physicians for accreditation surveys by creating and providing education, rounding using tracer methodology, providing other resources.
- Oversees the accreditation committee
- Assesses the organization for compliance with regulatory requirements.
- Oversees compliance with meaningful use and other regulatory programs.
4. Institutes and maintains effective communication throughout the organization that promotes use of the compliance Hotline, heightened awareness of the Standards of Conduct and understanding of new and existing compliance issues and related policies and procedures. - Acts as an independent review and evaluation body to ensure that compliance issues/concerns within the organization are being appropriately evaluated, investigated, and resolved.
- Identifies potential areas of compliance vulnerability and risk.
- Develops/implements corrective action plans for resolution of problematic issues.
- Responds to alleged violations of rules, regulations, policies, procedures, and standards of conduct by evaluating or recommending the initiation of investigative procedures.
- Develops and oversees a system for uniform handling of such violations.
5. Develop department operating budget and assure compliance with budget expectations. 6. Provides supervisory responsibilities to staff in the quality management department. JOB SPECIFICATIONS A. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES Knowledge: 5 years' experience in risk management, patient safety, or quality (required). Bachelor's degree or equivalent combination of education and work experience.
10 years' experience in healthcare environment.
5 years' analytics and regulatory reporting experience (preferred).
1 - 2 years management/supervisory experience (preferred).
Skills:
Microsoft Office including excel, word PowerPoint, outlook.
Use EHR
Proven ability to analyze, interpret, and display data
Abilities - Ability to communicate verbally
- Ability to compile complex reports and develop presentations
- Ability to compose letters and memorandums
- Ability to deal calmly and courteously with people
- Ability to deal with stressful situations
- Ability to finish tasks in a timely manner
- Ability to follow oral and written instructions and established procedures
- Ability to function independently and manage own time and work tasks
- Ability to lead work teams
- Ability to maintain accuracy and consistency
- Ability to maintain confidentiality
- Ability to build relationships and foster communication among stakeholders in clinical and non-clinical settings.
- Ability to negotiate, persuade and establish direction
- Ability to organize workflow
- Ability to plan, coordinate and develop multiple projects
- Ability to work as an effective team member
Benefits - Paid Sick Time - effective 90 days after employment
- Paid Vacation Time - effective 90 days after employment
- Health, vision & dental benefits - eligible at 30 days, following the 1st of the following month
- Short and long-term disability and basic life insurance - after 30 days of employment
Disclaimer:
The statements herein are intended to describe the general nature and level of work being performed by employees and are not to be construed as an exhaustive list of functions, tasks, duties, responsibilities and requirements of employees so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of Insight Hospital and Medical Center.
