Position Summary

The Director of Quality and Risk Management provides leadership and expertise to ensure the delivery of safe, high quality patient care services.

Essential Functions

• Oversees a hospital wide quality improvement program inclusive of all staff, develops and maintains a written quality improvement plan and annual evaluation of the plan’s effectiveness.
• Develops and maintains a performance measurement work plan and reporting calendar to ensure timely data collection, aggregation, analysis, and reporting of established performance measures related to key operational and clinical processes and outcomes.
• Manages electronic storage of quality improvement reports to promote ongoing access for key stakeholders.
• Oversees a corporate compliance program, develops and maintains a written corporate compliance plan and annual evaluation of the plan’s effectiveness; ensures that all required elements of a compliance program are addressed.
• Develops and maintains policies and procedures related to the corporate compliance program.
• Develops and maintains the written TBH Code of Conduct and ensures staff and Board members receive the appropriate training/education.
• Serves as a resource for the President for all external and internal compliance audits; ensures that corrective action plans are documented in a timely manner and effectively implemented.
• Oversees investigations relating to reports of known or suspected violations of the corporate compliance program or Code of Conduct.
• In consultation with the President, submits mandatory notification of known or suspected corporate compliance violations to the appropriate regulatory agencies.
• Develops and maintains up-to-date knowledge of corporate compliance requirements and related laws and regulations as mandated or recommended by OIG, CMS, and other agencies; attends outside corporate compliance trainings as directed by the President.
• Oversees a corporate wide risk management program, develops and maintains a written corporate risk management plan and annual evaluation of the plans’ effectiveness.
• Develops and maintains policies and procedures related to the corporate risk management program.
• Develops and oversees processes for internal incident reporting.
• Reviews incident reports and conducts follow up investigations as warranted.
• Investigates and evaluates claims and potential claims.
• Oversees a corporate wide patient safety program, develops and maintains a written patient safety plan and annual evaluation of the plan’s effectiveness and develops and maintains policies and procedures related to the patient safety program.
• Collaborates with the President in the investigation of clinical events including sentinel events, sentinel event near misses, and significant adverse events; leads and/or participates in the development of root cause analyses as directed by the President.

Non-essential Functions

• Performs other duties as assigned.

Position Requirements

• Master’s degree in Public Health, Healthcare Administration or Bachelor’s degree and 2-3 years of experience working in the healthcare field.
• Demonstrated leadership skills including excellent oral and written communication skills.
• Strong knowledge of healthcare clinical fundamentals, patient safety standards, and performance improvement standards.
• Strong knowledge of CQI tools and techniques, ability to perform data analytics, and lead performance improvement teams
• Computer skills and knowledge of applicable software programs.
• Ability to work with diverse populations.
• Flexibility with schedule.

Mental / Emotional Demands

• Exhibits strong leadership ability.
• Able to handle multiple priorities
• Uses independent discretion/decision making skills.
• Makes good decisions under pressure.
• Manages stress appropriately.
• Works alone effectively.
• Works with others effectively.

Physical Requirements

Medium Work – Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects.  Physical Demand requirements are in excess of those for Light Work.