Director of Quality and Risk

Neuropsychiatric Hospitals•Greenwood, IN

3h•Onsite

About The Position

NeuroPsychiatric Hospitals is seeking a Director of Quality and Risk for their Greenwood, Indiana location. NPH is a national leader in providing medical and neurobehavioral care to patients experiencing acute psychiatric distress. The role involves joining a team dedicated to exceptional, patient-centered care. The Director of Quality is responsible for supporting the implementation and monitoring of quality assurance measurements and audits, and for assisting in improving patient safety processes throughout the hospital. This includes coordinating and engaging in activities to proactively promote evidence-based best practices and resolve deficiencies, planning, developing, and directing system activities and protocols across NeuroPsychiatric Hospitals, preparing NPH facilities for surveys by accrediting and licensing agencies, and serving as a resource to all departments and personnel.

Requirements

Bachelor's Degree in healthcare field or pertinent program required.
3+ years of relevant healthcare quality and risk management experience.
Excellent verbal communication skills necessary in order present quality reports.
Maintain effective contacts with a variety of Hospital Personnel.
Professional knowledge of clinical practice, leadership, performance improvement and research statistics in order to conduct surveillance and prepare related reports at a level normally acquired through the completion of a Bachelor’s degree in related field.

Nice To Haves

Master's Degree preferred.
Prior leadership experience preferred.

Responsibilities

Implements and monitors quality goals and objectives to measure the organization’s processes and outcomes while administering programs that focus on improved outcomes of patient care or patient safety.
Interacts with physicians, nurses, department managers, supervisors, and any/all other staff members to provide resource information and identify new opportunities to improve service and reduce costs.
Generates effectual quality related policies and procedures for the department and hospital that ensures compliance with JC, OSHA, CDC, CMS and other county, state, and federal regulatory agencies.
Prepares reports, presentations and statistical data that go to the Quality Assurance and Performance Improvement Committee Meetings, facility's administration and other committees as needed. Analyzes data to identify trends and resource utilization for use in optimizing compliance.
Assists with the annual assessment of the quality control programs from the prior year activities.
Investigates incidents within the facility and coordinates with the Corporate Quality team to complete the root cause analysis and develop action plans to prevent incidents in the future.
Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving quality improvement.
Prepares the agenda for the Quality Council Committee meetings and holds regularly scheduled meetings.
Provides educational offerings for orientation and on-going in-services.
Performs mortality reviews in conjunction with the mortality committee and holds regularly scheduled mortality committee meetings.
Ensures all staff receive proper education on new or revised state and/ or federal regulations or Joint Commission standards.
Participates in Multi-disciplinary patient centered case conferences, as appropriate.
Assess and evaluate patients with infections and monitor patient outcomes on an ongoing basis.
Initiates follow-up on employee/patient exposures to communicable diseases.
Participates in root-cause analysis, sentinel events, adverse events and identifies trends as directed by regulation. Recommends ways to redesign systems for improvements if needed.
Oversee Patient Advocacy program.
Establishes/maintains good relationships with COO, CEO and DON’s and department leaders to promote a cooperative and constructive environment for improvement.
Promote “Quality is everyone’s business” to gain support, understanding and ownership among staff.
Other duties as may be assigned.
Complies with hospital expectations regarding ethical behavior and standards of conduct.
Complies with federal and hospital requirements in the areas of protected health information & patient privacy.
Understands and adheres to NPH’s compliance standards as they appear in NPH’s Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy.
Keeps abreast of all pertinent federal, state and hospital regulations, laws and policies as they presently exist and as they change or are modified.
Performs other duties as assigned.