Director of QualityRisk

Director of Quality/Risk - Ottumwa IA 52501
Full time permanent onsite role.

Salary - $110000 to $150000/ year with benefits.

Partial relocation assistance

Must-Haves

• Masters degree in Nursing other healthcare related fields required.
• Clinical degree (RN) required.
• 5 years of leadership and/or management experience in a healthcare setting in nursing risk and/or quality improvement.

Job Description
GENERAL SUMMARY OF DUTIES
The Director of Quality/Risk is responsible for governing the facilities regulatory compliance programs and takes the lead role in planning organizing and managing effective quality/performance improvement and risk management functions for all departments and divisions of ORHC. Elements include; safe environment clinical standards infection prevention patient advocacy clinical education professional property and general liability clinical standards and on-going systematic performance improvement programs.
The Director of Quality/Risk is supported and receives oversight from administration the hospitals Board of Directors and the hospitals parent company for the role and responsibilities for The Director of Quality/Risk.
Success in this position will be measured by improvement in the quality of services provided at ORHC by the perception that customers and the public have of ORHC and by meeting the expectations of various accrediting and licensing bodies.

SUPERVISOR CO
SUPERVISES Quality Staff and Clinical Educator

DUTIES INCLUDE BUT ARE NOT LIMITED TO

QUALITY/PERFORMANCE IMPROVEMENT/ACCREDITATION

1. Conducts the Quality and Performance Improvement Program for the facility by facilitating the service lines departments.

2. Is the Patient Safety Officer and Patient Safety Field Manager for the facility.

3. Develops the National Quality Program with senior leadership.

4. Prepares monthly operating review quality and patient safety slide deck with details of the current state and focus on the future goal attainment action steps.

5. Facilitates the external surveys from accreditors licensure verifications certifications including mock surveys and those that occur related to complaints reviews annual biennial triennial

6. Manages the readiness for survey programs.

7. Maintains regulatory readiness and conducts educational programs related to these.

8. Responsible for the electronic educational program for the organization.

9. Responsible for the infection control prevention and surveillance program.

10. Assures that programs initiatives processes and policies are in compliance with state federal and other accrediting bodies/regulatory agencies. Collaborates with facility leaders in expected unannounced active and ongoing survey readiness.

11. Is the administrator for the federal Harp formerly QNet program policy management software program and incident reporting system

12. Holds responsibility to conduct the Leapfrog Patient Safety program through the leadership for the facility

13. Engages medical staff directors managers front line staff and Board of Directors to develop implement and maintain a successful written organization-wide quality and risk programs.

14. Manages data collection to evaluate organizational outcomes and submits accurate data in a timely manner as required by regulatory agencies or as part of any volunteer/collaborative initiative

15. Responsible for tracking and trending incidents assuring ongoing process improvement and follows up with further investigation when appropriate reports information to senior management Medical Staff Board of Directors and/or Quality Committee as appropriate.

16. Assists in the implementation of departmental quality initiatives and analysis of outcomes data. Analyzes shares and assists with interpretation of outcomes data with appropriate staff medical staff and customers. Facilitates any action deeper analysis (root cause analyses) process review or policy change as indicated for any noted undesirable data/negative trends.

17. In collaboration with CNO assists in design and implementation of strategies to measurably improve quality of care for patients served.

18. Assures appropriate level of understanding awareness and compliance with all applicable Joint Commission CMS state and local agency laws internal/external regulations guidelines policies procedures and professional standards.

19. Coordinates the organizational Foundational Five Program.

20. Working with Human Resources analyzes the Culture of Safety survey results and utilizes the results in planning education and coordination of process improvement activities.

21. Other duties as assigned.

RISK MANAGEMENT
Monitors and manages risks and liabilities to ensure patient and staff safety; track/trends incidents follow up with further investigation when appropriate reports data to senior management Board of Directors Medical Staff and/or Quality Committee as appropriate.
Annual review and submission of the Risk Management Plan to Senior Leadership and the Board of Directors for approval.
Prepare and present an Annual Risk Management report including organizational risk exposure and mitigation to the Board of Directors.
Risk Management role in the organization
Develops coordinates and administers facility-wide systems for risk identification (variance reporting) investigation and reduction;

• Collect evaluate and distribute relevant data
  Communicates with clinical directors and department managers regarding occurrences issues findings risk management suggestions and applicable risk reduction strategies
  Review and analyze occurrence reports to identify trends making recommendations for corrective action if appropriate.
• Advises on issues related to risk and potential liability and legal exposure. (Informed consent decision making capacity surgical explants).
  Inspects patient care areas for risk and performs focused risk assessments to assess loss potential.
  Receives and investigates reports of product problems to determine appropriate response has been taken.
  Conducts review of unanticipated events patient harm events and RCA.
  Participates on committees directed towards promoting patient safety issues.
  Assures that risk programs initiatives processes and policies are in compliance with state federal and other accrediting bodies/regulatory agencies. Collaborates with other leaders in active and ongoing survey readiness for risk reduction.
  Promotes maximum confidentiality by limiting access to such information.
  Gather and analyze data and prepare reports to facility leadership and outside agencies as required.
  Conducts risk management educational programs regarding healthcare risk management and related subjects
• Complaint and Grievance management and service recovery
  Ensures amicable timely and confidential response to patient complaints and liability issues. Analyze trends and patterns of patient complaints and identify areas for improvement.
• Loss prevention/patient safety develop loss prevention programs
  Participate in proactive analysis of patient safety and clinical processes including new equipment new service line.
  Participate in the process of disclosure for medical errors
• Ensure risks are minimized by validating regulatory survey report recommendations have been implemented and sustained.
  Credentialing - participate in credentialing process to identify common red flags that might indicate a risk for malpractice claims.
  Appropriate use of Medical Equipment / Safe Medical Device Act reporting.
  Works with Materials Management and Pharmacy to ensure procedures are in place to track document store/handle and manage recalls.
  Be familiar with the Safe Medical Device Act and the reporting requirements. Patient and employee safety and security review daily variances and security reports for potential risk exposures
  Participates with the Peer Review Committee and facilitates external vendor event reviews
  Collaborate with Marketing in monitoring social media and news sources for publications that could put the organizations reputation at risk and in the development of marketing mitigation strategies that improve and/or preserve the organizations public image.
  Facilitate and/or assists in Root Cause Analysis (RCA) Failure Mode and Effects Analysis (FMEA) and Sentinel Event investigations
  Participate in new service planning by conducting a risk assessment and marketing material review
  Policy/procedure development and review Ensures the facility has a process and it involves subject matter experts.
• Insurance- provides general knowledge and oversight of facility insurance programs.
• Claims Management: participates as a team member in negotiating settlements assists legal counsel in accessing facility records personnel and serves as facility representative in depositions trial and mediation may act as a corporate representative during pretrial depositions and trial. Evaluates claim for defense strategies and exposures.
• Oversees investigation of incidents/accidents/events that could lead to financial loss professional liability general liability and workers compensation.
  Communicates identified risk to CEO and HSC claims director/risk manager and initiate incident report.
  Interview employees immediately after an adverse event to obtain first-hand information about the event and evaluate potential liability and provide support.
  Verifies that the following information is accurate available and secure for any probable claim: Medical records patient billing records relevant policy and procedure incident reports and claim investigations.
  Initiates medical write-offs to mitigate potential claims.
  Investigates risks involving actual or potential injury to patients visitors and employees collecting information preserving evidence necessary to prepare for the defense of claims.
  Works with legal counsel to coordinate the investigation processing and defense of claims against the facility; records collects documents maintains and provides to defense attorneys any requested information and documents necessary to prepare testimony in pending litigation.
  Participates in monthly legal calls for the facility.
  Collaborates with HSC Claim Director and Defense Counsel in the legal process.
  Assists in preparation of employees for deposition.
• Other duties as assigned.

KNOWLEDGE SKILLS & ABILITIES

• Maintains strict confidentiality privacy compliance regulatory accrediting standards and code of conduct.
• Demonstrate leadership communication and interpersonal skills.
• Ability to communicate effectively both verbally and in writing.
• Ability to lead quality and risk programs plans committees in establishment of quality/performance improvement priorities and work with directors/managers to develop quality initiatives.
• Basic analytical knowledge and skill needed to facilitate the quality risk education infection prevention programs with directors/managers in establishing ways to measure performance and progress towards desired improvement goals.
• Must be well organized and able to set priorities have good presentation skills strong interpersonal skills and ability to work effectively with the others peers senior leaders medical staff and Board members.
• Must have knowledge of state and federal regulations (federal law DEA OSHA CMS OIG etc.) and expert knowledge of The Joint Commission standards and accrediting licensure verification certification for programs of the facility (CAP CARF AAAHC ACHC as applicable).

CERTIFICATE/LICENSE

• RN licensure in the state of Iowa.
• CPPS within one year of hire and CPHQ certification preferred.