Director - Quality & Risk Management

Island Health is seeking an experienced Director of Quality & Risk Management to join our dynamic healthcare team for our hospital in Anacortes, WA. 

Work Schedule:

• 1.0 FTE/40 hours per week
• Exempt
• Day Shift

Salary Range: $120,660 - $180,980

Job Purpose:

• The Director of Quality and Risk Management provides organization-wide leadership for Quality activities including Performance Improvement functions, medical staff peer review, DNV and regulatory agencies standards and requirements oversight and education. Leads all risk management activities including investigating and responding to patient complaints, working with hospital’s insurance carrier to monitor claims and modify risk, investigating and filing potential liability claims, monitoring and reducing employee injuries, patient falls, medication errors and other safety issues.

Duties:

• Design, implementation and ongoing improvement of the Continuous Quality Improvement-Performance Improvement Program and projects.
• Leadership for Island Hospital’s benchmarking, outcome studies, customer satisfaction surveys, and quality improvement projects.
• Provides direction and coordination of the medical staff peer review process and serves as a resource for the credentialing process.
• Facilitation of the root-cause analysis of quality issues including system problems and adverse events or patterns.
• Development and implementation of educational programs for hospital patient care and support staff based on identified learning needs.
• Providing leadership for continual institutional readiness for satisfactory regulatory review by DNV, Department of Health, and other state and federal regulatory agencies as designated by the Administration, Board, and laws by:
  • providing information on requirements / standards
  • serving as a resource and periodically reviewing readiness
  • conducting or overseeing education
  • coordinating surveys
• Providing and maintaining necessary reports, analysis and data, assuring that patient and peer confidentiality is maintained and protected.
• Preparation and control of departmental budget.
• Working with hospital insurance carrier to minimize liability to the hospital and clinics.
• Investigating, tracking and responding to patient complaints.
• Monitoring and reducing all employee and patient risk indicators.
• Investigating, tracking and reporting liability issues and working with insurance carrier on resolution.
• Demonstrates knowledge of the principles of growth and development over the life span and can identify each employee’s and patient's requirements relative to his/her age-specific needs.
• Contributes to the financial stability of the hospital by developing and maintaining annual operating budgets within prescribed parameters.
  • Accountable for budgetary compliance for Quality/Risk Department.
  • Anticipates budgetary impact of service or program changes and develops contingency plans.
  • Develops and interprets budgetary parameters from departmental and hospital impact.
  • Evaluates statistical data to determine trends, potential for improvement and develops same.
  • Informs staff of budget parameters, constraints and opportunities. Educates staff in methods of analysis.
  • Advises hospital clinical department heads of funds necessary for upcoming clinical education programs and works with staff and managers to assure budgetary compliance with parameters.
• Assures delivery of quality patient care through definition and implementation of nursing standards for care.
  • Directs and facilitates integration of nursing care standards into educational offerings to staff based on identified learning needs.
  • Evaluates quality of patient care provided using the nursing process and care standards as a framework in collaboration with staff and other disciplines.
  • Interprets and modifies as appropriate, standards to assure consistency with current professional practice and scientific advances.
  • Mentors, educates, and promotes patient safety functions throughout the organization.
• Promotes achievement of hospital goals and objectives, mission and vision. Assures integration of Nursing Philosophy into daily practice.
  • Fosters key relationships spanning multiple departments and involving appropriate individuals to achieve goals and objectives.
  • Elicits cooperation of staff to achieve departmental and hospital goals through communications that are clear, objective and reflect a broad perspective.
  • Utilizes Nursing Philosophy as a basis for designing departmental services, assisting staff in development and growth and facilitating team collaboration.
  • Promotes effective services for compliance with state of the art practice, community standards and regulatory requirements.
  • Evaluates clinical services for compliance with state of the art practice, community standards and regulatory requirements. Continuously improves quality of services provided.
  • Facilitates changes in service through appropriate interpretations and implementation of research. Involves staff in identification and implementation of research.
  • Develops a plan to facilitate educational opportunities on quality and risk management topics to staff at Island Hospital
  • Supervises data collection for Core Measure requirements, and develops and implements a performance improvement plan as indicated.
  • Supervises data collection and analysis of quality indicators according to national, regional, and local benchmarks as required by regulation and as selected by Administration and Medical Staff.
• Assures optimum quality of performance through sound supervision of subordinates.
  • Assists staff in setting individual performance goals and objectives. Provides direct and indirect feedback on performance on a timely basis.
  • Facilitates optimal team function by establishment of effective shared decision making, communication systems and supporting policies and operating guidelines
• Serves as a change agent and leader for facilitating delivery of care, implementation of change and professional growth of staff. Works effectively with all disciplines demonstrating knowledge of and respect for capabilities and achievements of others. Facilitates development of effective working relationships between disciplines. Participates in Medical Staff meetings.
• Maintains expert level of knowledge concerning principles of CQI and process / performance improvement. Educates staff, physicians, board in CQI philosophy and methodology. Assures integration of CQI in daily departmental processes. Establishes measurable outcomes including fiscal to document improvement as a result of CQI efforts. Continuously improves program assuring it is reflective of current state of the art. Maintains records and reports and assures significant results are discriminated as appropriate. Annually assists in establishing program goals and implements system to assure compliance with plan, prepares and discriminates annual report of CQI program including financial impact of efforts.
• Serves as staff to the Medical Staff for Quality Assessment. Advises on the most efficient and effective methods of data acquisition, analysis, reporting and maintenance in order to facilitate utilization as well as compliance with regulatory bodies. Performs first level review of data on a regular basis. Assures access to confidential reports is limited to need to know and restricted from unauthorized access. Identifies trends of concern and brings to attention of appropriated person(s). Performs special studies as appropriate or requested. Prepares reports as needed or requested. Expert knowledge of regulatory requirements of such programs and able to translate requirements into practical, efficient useful program specific to this institution.
• Serves as an expert in regulatory standards, both voluntary and mandated. Regularly audits specified functions to assure compliance with current requirements and works effectively with those impacted to assure full implementation of needed changes and improvements. Assures compliance with reporting requirements. Serves as the institutional contact person for interactions with regulatory agencies. Assures constant compliance with most current DNV standards. Monitors developments in alternative regulatory agencies for consideration. Responsible for assuring organizational readiness for on-site reviews.
• Must have demonstrated ability to interact positively with Administration, Directors, Managers, Supervisors, peers, co-workers, subordinates, patients and visitors.
• Must meet regular attendance standard and must stay at or below average sick leave utilization levels.

Skills/Qualifications:

• Knowledgeable and proficient in CQI principles including use of statistical analysis. Can utilize techniques in team meetings in order to assist staff in development of knowledge and skills in CQI.
• Demonstrated strong written and verbal communication and leadership skills.
• Proficiency in use of statistical thinking including use of control and run charts and applied statistical analysis.
• Extensive knowledge of computers and the ability to independently use them.  Proficient in the use of MS Office products; Word, Excel, Outlook, etc.
• Ability to apply principles of logical or scientific thinking to define problems, collect data, establish facts, and draw valid conclusions; to interpret an extensive variety of technical instructions in mathematical or diagrammatic form. Deal with several abstract and concrete variables.

Requirements:

• Current WA State RN License or Medical equivalent.
• Master’s degree in Nursing or related field.
• A minimum of five (5) years of management and quality experience preferred.
• NIMS Training: ICS-100 and ICS-200 completed within 6 months of hire.

Work Environment:

• While performing the duties of this position, the employee is exposed to inside environmental conditions, protected from weather conditions but not necessarily from temperature changes. The employee may be exposed to dust, pollens, pollutants, fumes and communicable diseases as related to a health care environment. The noise level in the work environment is usually moderate.

Physical Demands:

• While performing the responsibilities of this position, the employee is regularly required to talk, and have hearing sufficient to understand conversations, both in person and on the telephone. The employee is often required to sit for potentially long periods of time throughout the workday. Manual dexterity of hands and fingers, to handle or feel and to manipulate keys on a keyboard. The employee is occasionally required to stand; walk, climb or balance; stoop, kneel, or crouch; lift and/or move up to 25 pounds and use hands to finger, handle, or feel objects, tools, or controls, and reach with hands and arm. Vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus sufficient to operate computer systems. Reasonable accommodation can be made to enable people with disabilities to perform essential functions of this position in relation to the physical demands detailed above.

Salary Range: $120,660 - $180,980