The Quality/Risk Director is responsible for helping to create an environment and culture that enables the facility to fulfill its mission by meeting or exceeding its goals, conveying the hospital mission to all staff, facilitating staff accountability for their performance, and motivating staff to improve their performance.
The Director manages, directs, and plans all aspects of Quality and Risk Management. The Director is responsible for a hospital -wide quality management program and works with hospital administration, departments, and the medical staff to monitor and evaluate the quality of delivery of patient care services within the hospital. The Director will have access to all medical records for the facility. The Director also ensures proper compliance with regulatory agencies, accrediting bodies, corporate and hospital policies and procedures and works to develop, implement, and maintain quality assessment and improvement programs within the facility.
This position will support cultural diversity by ensuring that the delivery of quality, equitable and culturally competent patient-centered care is provided; promoting and maintaining an inclusive work environment and culture that is respectful and accepting of diversity; and ensuring that cultural diversity and sensitivity training is part of new employee orientation on an on-going basis to meet the needs of the patient population served in the hospital.
Job Code: 100141
License or Certification: - Licensed or Certified according to individual state requirement Education,
Training and Years of Experience: - Bachelors degree in healthcare or related field preferred - Quality and/or Risk Management experience including primary responsibility for performance improvement activities, regulatory compliance, conflict resolution, leadership and risk management activities
Machines, Equipment Used: - General office equipment such as telephone, copy machine, fax machine, calculator, computer.
Physical Requirements: - Good visual acuity and ability to communicate. - Ability to lift a minimum of 30 pounds and ability push/pull a minimum of 50 pounds, which includes the lifting, pushing and/or pulling of medical supplies and equipment and the transferring and repositioning of patients. Reasonable assistance may be requested when lifting, pushing, and/or pulling are undertaken which exceeds these minimum requirements. - Ability to withstand prolonged standing and walking. - Ability to reach, stoop, bend, kneel, and crouch are required for patient care functions and in setting up and monitoring equipment.
Compliance: - Adheres to the company's Standards of Business Conduct. - Maintains current licensure and/or certifications, if applicable.
Skills and Abilities: - Ability to speak, read, write, and communicate effectively. - Ability to coordinate, analyze, observe, make decisions, and meet deadlines in a detail-oriented manner. - Ability to work independently without supervision.
Environmental Conditions: - Indoor, temperature controlled, smoke-free environment. Occasional outdoor exposure. - Exposure or potential exposure to blood and body fluids may be required. - Handicapped accessible. - May work under stressful circumstances at times.
Proficiency or Productivity Standards: - Meets established attendance standards. - Adheres to hospital/department dress code including wearing ID badge. - May be required to work weekdays and/or weekends, evenings and or night shifts if needed to meet deadlines. - May be required to work on religious and/or legal holidays on scheduled days/shifts. - Will be required to work as necessary during disaster situations, i.e., before, during or after a disaster. - May be required to stay after workday to assist after a disaster situation until relief arrives. - May be required to perform other duties as assigned by supervisor.