Job openings in a hospital located in the Tri-Cities, WA area for a Director of Quality, Risk and Performance Improvement to join their team. The hospital has over 1000 employees and the Director will oversee 4 FTEs.
Directs the operational, financial management and personnel resources for Quality Performance, Medical Staff, Infection Prevention and Risk Management. Functions as the coordinator for the Hospital-wide quality performance program. Coordinates assigned certification, patient safety and regulatory programs. Reports to the CNO.
Develops, implements reviews and maintains the Quality Program including but not limited to the following:
- Develop operations, positions, budget and assignments to assure coordination of all assigned functions.
- Direct, oversee and coordinate activities in legal issues, quality improvement activities, risk management and infection control.
- Plans and evaluates multidisciplinary process improvements relating to quality of clinical care/practice/service.
- Assist medical staff, clinical and non-clinical departments with performance improvement activities.
- Develops, prepares for and evaluates compliance with all regulatory requirements (i.e., Joint Commission, Centers for Medicare & Medicaid and Department of Health) process improvement, risk management, medical staff, and infection prevention.
- Facilitate and monitor the performance improvement process throughout the organization and provide support and education as it relates to the performance improvement plan.
- Coordinate the performance improvement processes and aggregate the results to assist in providing Quality Council and Quality Management Committee with information necessary to assess and evaluate services, including legal issues.
- Prepare for and coordinate Joint Commission, Centers for Medicare & Medicaid and Department of Health surveys.
- Direct the development of and monitoring of Infection Control Program.
- Resource for designation programs (i.e., stroke, trauma, etc.). Develops and provides reports on progress/performance of Quality, Risk, Medical Staff, Infection Prevention and Compliance programs as requested
- Coordinate, develop, review, revise and implement the Quality Committee
- Implementation and oversight of the National Quality Program
Develops, implements reviews and maintains the Risk Program including but not limited to the following:
- Implementation and oversight of the Compliance Program.
- Receive and manage information on occurrences and near-misses; reviews and analyze for potential liability; provide and/or coordinates investigation and follow-up of serious occurrences and sentinel events with participation at the level appropriate to the event and in compliance with regulatory regulations.
- conducts Root Cause Analysis (RCA) in collaboration with the Director of Quality and appropriate leadership in a timely manner.
- Works with legal counsel in investigations, processing and defense of claims against the hospital, clinics, or other service sites belonging to or operated by the hospital. May request legal opinions or advice, as needed.
- Establishes and implements policies and procedures to carry out goals and objectives.
- Maintains risk management statistics and files in compliance with Joint Commission, CMS, and other regulatory agencies.
- Assists department leaders in designing risk management mechanisms in their departments as appropriate
- Receives claims or potential claims related to professional liability, analyzes actual and potential risk, assesses liability and probability of legal action; and transmits and coordinates with legal counsel.
- Assists in processing summons and complaints served on present and previous employees.
- Interacts with management and legal counsel to respond to claims or issues to facilitate settlement at an early stage. Works to resolve complaints/issues before they develop into professional liability claims.
- Coordinates legal activities.
- Takes appropriate steps to ascertain that risks are minimized through follow-up and action on all regulatory/insurance survey reports recommendations/deficiencies.
- Receives and manages information on occurrences; reviews and analyzes for potential liability; provides investigation and follow-up of serious occurrences and sentinel events with participation at the level appropriate to the event and in compliance with regulatory compliance.
- Interfaces with insurance carriers regarding claims, applications, and on-going communication.
- Works with hospital legal counsel in investigations, processing and defense of claims against the hospital. May request legal opinions or advice. In collaboration with legal counsel, works out effective mechanisms and procedures to ensure appropriate and timely response to issues or events with serious potential for liability.
- Responds to professional liability and hospital liability questions posed by hospital staff and medical staff.
- Maintains awareness of legislative and regulatory activities related to health care risk management.
- Presents periodic in-services and routine orientation for employees and medical staff regarding healthcare risk management and related subjects to enhance awareness of their role in reducing liability exposures and for reporting occurrences.
- Disseminates information on claim patterns and risk control, provides recommendations and guidance for managing and reducing risk.
- Manages incident reporting system.
- Recommends and facilitates change in the organization to improve patient safety, patient satisfaction and to reduce risk.
- Leads initiatives to develop proactive risk assessment strategies across services to identify and mitigate patient safety risks.
- Leads in development of a mechanism for internal communication of patient safety issues
- Investigates complaints from the confidential hotline, corporate hotline, and from patients
- Works collaboratively with hospital and the Medical Group leadership to report and improve patient satisfaction
- Manages incident reporting system in conjunction with Risk Manager.
Develops, implements reviews and maintains the Medical Staff Program including but not limited to the following:
- Develops, implements, reports outcomes and maintains peer review program
- Ensures peer review program is compliant with regulatory bodies
- Works with medical staff leadership to develop, maintain and implement a credentialing program that is compliant with regulatory bodies.
- Coordinates and records medical staff meetings
Develops, implements reviews and maintains the Infection Prevention Program
Develops, implements reviews and maintains the Infection Prevention Program
- Direct, develop, review, update, and enforce policies and procedures to reflect compliance with Medicare (CMS), Medicaid, Joint Commission (or other accrediting body if changed), and other Federal and State requirements.
- Chairs Regulatory Readiness Committee, for sustained compliance with regulatory, accreditation and certification requirements (DOH, CMS, JC, etc.).
- Oversee follow-up on incident reports.
- Works closely with the Compliance and HIPAA Privacy Officer(s) with regard to the Risk Management aspects of Compliance and Privacy.
- Serves as primary liaison between the hospital and investigators from regulatory agencies, such as the WA State Department of Health and CMS.
- Provides oversight and direction for corrective action plans required by any regulatory, accreditation, or professional board agency
- Minimum of five (5) years comparable experience with at least three (3) years at a leadership level required.
- Bachelor’s degree and RN license required.
- CHPQ strongly preferred.
Welcome to the Tri-Cities where 300 sun-filled days offer visitors a year-round outdoor paradise. Fun in the sun is a way of life in the Tri-Cities; river action abounds on the Columbia, Snake, and Yakima rivers. Recreational and sports enthusiasts will love the Tri-Cities. Visitors can enjoy one of the three professionals sports teams. And with everything from bicycling to bowling, hunting to fishing, and soccer to water-skiing, the recreational opportunities are endless. The area’s ten beautiful courses challenge the most experienced golfer, but can be enjoyed by the beginner as well. After savoring just one of the local premium wines, visitors will understand why the area has been rightfully called the “Heart of Washington Wine Country.” The Tri-Cities boasts more than 160 wineries within a 60-mile radius, producing some of the finest wines in the world. The confluence of the Snake, Yakima and Columbia Rivers has produced an aquatic playground second to none. The area’s inviting waterways beckon water lovers from all over the region to enjoy sailing, power and pleasure boating, waterskiing, swimming, fishing, windsurfing, and much more.
Competitive Salary Range!
Executive & Management Recruitment Services
(415) 770-1200 – call/text-the quickest way to reach me