SUMMARY
This position provides enterprise-wide oversight of the Hospital and Clinics' Quality, Risk Management, and Patient Safety.
Reports directly to the Executive Director of Patient Care Services. Works closely with leadership, the Executive Team, and the Board of Trustees on the cultivation and maintenance of a culture of safety.
Provides oversight for organizational readiness and follow-up from any regulatory or accreditation survey. Provides oversight for the organization's performance improvement processes
Monitors credentialing scorecards, peer review, and provider-related quality initiatives. Assures timely evaluation and management of all complaints and grievances.
Assures compliant responses. Responsible for oversight of all quality metrics, analysis of event monitoring, and follow-up of patient experience activities.
Works collaboratively with employees of all levels. Works collaboratively with professional liability and other insurance carriers on claim review, analysis, and risk mitigation.
Skilled in facilitation RCA, FMEA, and other root cause and effect related tools. LEAN / Six Sigma training is preferred and encouraged.
Mentors direct reports / department leaders in individual areas of oversight including Quality, Risk Management, Patient Experience, Patient Safety, Survey Readiness and Follow Up, Infection Prevention / Control, and Employee Health.
REQUIREMENTS
- Bachelor’s degree in the healthcare related field required
- Master’s degree or JD preferred.
- Certification in Risk Management (CPHRM), Quality (CPHQ), or Patient Safety (CPPS) is required within 18 months of job acceptance.
- Experience in successfully leading a Quality or Risk Management Department with quantified performance improvement required.
- Clinical department leadership experience with successful quantifiable performance improvement may be accepted in exchange for QRM dept.
leadership experience.
- Strong communication skills, and ability to work calmly and effectively under pressure and with all types of employees, providers, patients, and families.
- TeamSTEPPS, Just Culture, Human Factor, and Patient Safety Culture training preferred.
- Accreditation and Regulatory survey experience preferred TJC survey experience preferred.
- Emotional maturity and ability to maintain confidentiality in all matters.
- Strong organizational, planning, and data interpretation and analysis skills.
- LEAN / Six Sigma training is preferred and encouraged.
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