Director OF Quality, Risk, & Compliance

We are an EEO employer, and all hiring practices and other terms and conditions of employment shall be maintained and conducted in a manner that ensures compliance with all applicable federal laws.

Position Summary

Responsible for planning, organizing, developing and directing applicable performance improvement, quality assurance, risk and compliance activities and service initiatives, including but not limited to accreditation, medical home, vaccine management, clinical quality and risk, standards and practice in accordance with current applicable federal, state, and local standards, guidelines and regulations.

Duties & Responsibilities

Quality Improvement

• Collects, coordinates, and maintains informational reports from all departments and committees as outlined in the Performance Improvement (PI) Plan.

• Provides direction and oversight for practice transformation initiatives, including:

• Medical Home

• Meaningful Use and related projects

• Accreditation

• Plan, develop, and implement clinical quality initiatives.

• Coordinates and monitors the organization-wide PI Plan to maintain compliance with The Joint Commission, CMMS, and other regulatory agencies.

• Evaluates and improves the systems, forms, procedures, methods, and motions used in accomplishing all PI work.

• Prepares reports for Board of Director meetings, Medical Executive Staff meetings, and Medical Staff meetings.

• Assists Medical Staff in evaluating the quality of patient care and in developing criteria and methods for such evaluation.

• Provide direction and oversight for the vaccine management program, including training and education.

• Assists the Chief Medical Officer in the planning, development and implementation of clinical education strategies of medical clinical support staff and providers Participates with IT staff as a clinical resource and operation liaison.

• Plans, develops and implements organizational health and safety programs.

• Provides clinical metrics support and analysis for various federal, state and grant specific reporting including 330 Operations Assessment, UDS, IAP and OHIT.

Compliance

• Updates, implements and administers the HCHN corporate compliance plan and policies to assist staff in meeting regulatory compliance expectations.
• Communicates and updates changes in regulatory compliance standards to the HCHN staff including the HRSA compliance manual, PINs, PALs, etc. Acts as a clinical resource to other departments in compliance areas.
• Monitors complaints in compliance and reports any compliance issues to the COO.
• Performs other compliance-related duties as assigned.

Risk Management

• Updates, implements, and administers the risk management plan in cooperation with the performance improvement committee.
• In cooperation with clinical leadership, researches, writes, and implements risk management policies that decrease HCHN's potential liability and risk exposure.
• Investigates and tracks clinical risk management incident reports to identify adverse trends. Coordinates with clinic leadership in reviewing communication and response to patients and families regarding complaints and incidents.
• In cooperation with the CMO, coordinates peer review activities
• Coordinates and provides risk management training for staff.
• Coordinates with site leadership to administer patient experience surveys and formulates action plan to respond to patient experience survey results.
• Tracks patient complaint/grievance processes and collaborates with site leadership on resolution before they evolve into liability claims.
• Coordinates with HR and medical records departments in the risk management segment of the medical malpractice claims program.
• Works with CMO and clinic providers to review and perform risk assessment as part of the malpractice claims management process to ensure that providers are operating within their scope of practice and proper standards of care are being met.
• Is trained in all aspects of infection control and prevention practices and is actively involved in staff education and training on infection control practices.
• Completes annual risk management training through ECRI (Emergency Care Research Institute).
• Performs other risk management-related duties as assigned.

Infection Control

• Leads staff in adhering to disinfection, infection control, and sterilization practices, ensuring compliance with established regulatory guidelines.
• Participates actively in infection prevention and control activities, including surveillance, reporting, and responding to infection risks.
• Is trained in all aspects of infection control and prevention practices and is actively involved in the staff education and training on infection control practices.
• Develops and implements infection control policies and procedures.
• Ensures all medical equipment, devices, and surfaces are properly disinfected and sterilized according to established protocols.
• Maintains a clean and sanitary environment in patient care areas to prevent the spread of infections.
• Performs other duties related infection control and prevention as assigned.