About The Position

This position has overall responsibility for the Quality and Risk Management program. Responsible for regulatory compliance including external reporting requirements for the Department of Public Health (DPH). Provide oversight of risk management and patient safety processes to minimize risk to the organization and provide a culture of safety and healing. In conjunction with the clinical and system leadership, directs and coordinates Safety, Quality, and Performance Improvement initiatives. Collaborate closely with home care and hospice leadership to ensure clinical competencies and quality patient care.

Requirements

  • Bachelor’s degree in nursing, public health, health administration, or related field.
  • Five (5) years progressive leadership experience in healthcare system management overseeing Compliance, Quality, Patient Safety, or related area.
  • Working knowledge of healthcare quality and patient safety management, data sets and databases, benchmarking, outcome measurement, team development. Knowledge of regulatory compliance, quality improvement science and analytics.
  • Possess strong analytic skills, ability to interpret data; facility with using Excel.
  • Sound critical thinking/decision-making skills and the ability to function well under pressure.
  • Ability to cooperate in working with others to facilitate problem resolution with focus on process or system improvement.
  • Excellent verbal, written and presentation communication skills and ability to build relationships.
  • Highly developed organizational, interpersonal, and management skills.
  • Proficiency with Microsoft office applications.
  • Good leadership skills.
  • Knowledge of credentialing and peer review.
  • Ability to lead/facilitate change and motivate staff and physicians.
  • Must be able to sit, stand, walk, and talk most of the time; stoop, kneel, or crouch occasionally.
  • Must be able to use hands to finger, grasp and feel.
  • Ability to lift up to 10 pounds occasionally.
  • Close, distance, color, peripheral, depth perception, and the ability to adjust focus.
  • Must be able to clearly recognize alarms, understand and follow calls and instructions.

Nice To Haves

  • Master’s degree in nursing, public health, health administration, or related field.
  • Ten (10) years progressive leadership experience in healthcare system management overseeing Compliance, Quality, Patient Safety, or related area.

Responsibilities

  • Initiates and oversees the development of a comprehensive Safety, Quality, and Performance Improvement program inclusive of the analysis and trending of data related to initiatives.
  • Provides strategic oversight for patient safety and quality committees with accountability for distribution of organizational communication.
  • Provides overall direction necessary to ensure clinical services are provided in accordance with standards established through state and federal regulations, TJC accreditation standards, including National Patient Safety Goals, and are evidence-based.
  • Accesses organizational compliance with accreditation standards and regulations related to clinical care in collaboration with entity leadership and staff.
  • Identifies areas of vulnerability and directs the development of strategies to enhance compliance.
  • In conjunction with medical staff and system leadership, directs and coordinates safety, quality, and performance improvement initiatives.
  • In collaboration with clinical staff and service chiefs, participates in the monitoring, reporting and improvement activities related to clinical guidelines, healthcare quality and safety initiatives, accreditation, and regulatory requirements.
  • Manage department staff in the performance of duties, setting standards, providing development and training, perform evaluations and set goals.
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