QUAL005 Director of Quality and Risk Management

Position Summary

The Quality and Risk Management Director manages, coordinates organizational activities to ensure optimum preventative risk management. The Quality and Risk Management Director develops and implements policies and protocols, analyzes all potential risk in the healthcare facility, develops strategies to mitigate those risk, coordinates and oversees investigations into incidents that could result in an exposure to liability with focus on reduction of the hospital's exposure to litigation in an advisory capacity to management for the correction of errors.  The Quality and Risk Management Director establishes mechanisms for early substantiation of potentially litigious events, the preservation of evidence, verification of personal recollections and identification of defensible issues. The Director of Quality and Risk Management is responsible for the development, implementation, oversight and management of the facility's quality and safety processes, coordination of programs and/or processes designed to assess and evaluate the risk, quality and safety of patient care and outcomes including medical staff quality processes, direction and oversight of regulatory compliance initiatives including continual survey readiness activities, medical staff credentialing processes, the implementation of High Reliability and Safety within the healthcare system, facilitation of consistency in facility policies and practices.  The Quality and Risk Management Director reports to the SARH President.        

Qualifications/Experience

Education: 

Bachelor's degree in nursing or pertinent healthcare related field is required. Master's degree in nursing or healthcare related discipline is preferred.

Experience: 

Three (3) years’ experience in medical risk management / quality in an acute care setting required

Other Skills:

Demonstrated knowledge of risk management principles and issues regarding patient safety, strong leadership qualities and ability to function as an effective change agent. Must demonstrate ability to develop and maintain strong working relationships with the Medical Staff, Department Leaders, and Hospital Staff throughout the facility. Must exhibit excellent communication and interpersonal skills. Must be capable of working independently and autonomously. Position requires working knowledge of computer systems including Microsoft Excel and Health Information Management. Must be able to function effectively and meet deadlines timely. Must possess a working knowledge of Quality Improvement principles and statistical methodologies and experience in oversight/management of regulatory compliance including Joint Commission, CMS and State regulations is required. Demonstrated ability to develop and maintain strong working relationships with Quality Officers, Executive Leaders, Medical Staff, Department Leaders, and Hospital Staff throughout the SARH healthcare system. Must exhibit excellent communication and interpersonal skills. Position requires working knowledge of computer systems including Microsoft Office applications. Maintain current state clinical licensure and/or certifications relevant to position 

Licenses/Certificate:

Current licensure to practice as an RN in the State of Arkansas (includes multistate

Certification as a Professional in Healthcare Risk Management (CPHRM) is highly preferred.                              

Essential Job Functions

To perform this job successfully, an individual must be able to perform each of the following Essential Duties satisfactorily.  Reasonable Accommodations may be made to enable qualified individuals with disabilities to perform the Essential Duties of the position, provided it does not create undue hardship on SARH.

Develop and implement strategic plans for quality improvement.

Establish and maintain quality standards and benchmarks.

Design and manage quality control processes.

Ensure compliance with relevant regulatory standards and guidelines.

Conduct audits and surveys to assess the quality of products or services.

Analyze data to identify areas for improvement in the quality system.

Develop and deliver training programs on quality improvement.

Work with department managers to implement quality improvement plans.

Manage and resolve issues related to quality non-compliance.

Monitor and report quality metrics to senior management.

Collaborate with cross-functional teams to drive and enhance quality initiatives.

Develop and implement risk management policies and protocols.

Analyze all potential risks in the healthcare facility and develop strategies to mitigate those risks.

Coordinate and oversee investigations into incidents that could result in an exposure to liability.

Work closely with various departments to ensure the organization complies with rules, regulations, and standards.

Conduct training for staff on risk management issues and preventive measures.

Manage liability claims, patient complaints, and risk management cases.

Perform regular audits to ensure compliance with standards and effectiveness of policies.

Prepare reports and statistical data for hospital leadership on risk management issues and strategies.

Engage in patient safety initiatives to create a safe environment in the hospital.

Collaborate with legal and insurance professionals on risk-related matters.

This job description is a summary of the typical functions of the job, not an exhaustive or comprehensive list of all the possible job responsibilities, tasks, and duties you may be asked to perform when they are assigned.