Independent Contractor/System Director, Quality Improvement and Risk Management
This Consultant position is responsible for the development, direction and effective implementation of comprehensive hospital-wide quality improvement and risk management programs including external reporting, patient satisfaction and safety, infection control and outcomes management.
Essential Job Duties:
- Lead hospital-wide effort to educate organization regarding Performance Improvement (PI) and risk reduction philosophy, methodology, tools, techniques and emerging trends.
- Provide organizational leadership in clinical process improvement.
- Act as consultant to all departments and medical staff in development of PI plans, initiatives and measurement strategies.
- Provide direction for information management support to Environment of Care committees.
- Develop and continuously improve the hospital-wide Performance Improvement/Patient Safety program.
- Collaborate with Medical Staff management regarding peer review activities to ensure program effectiveness, goal achievements, contemporary state of the art practices and regulatory compliance.
- Prepare summary reports of key Performance Improvement/Patient Safety activities, actions, outcomes and trends for appropriate audiences.
- Serve as central repository for organization-wide Performance Improvement and Patient Safety activities and results.
- Develop, implement and monitor each Avanti hospital’s Infection Prevention and Control Program based on evaluation of organizational expertise, evidence based care and applicable law, regulations and best practices.
- Update and maintain risk reporting and risk management system including sentinel and critical event reporting and follow-up.
- Ensure compliance with Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP) federal, state and local requirements.
- Plan, budget and organize department to accomplish operational and strategic objectives.
- Develop PI activities that effectively reduce exposure to Pay for Performance penalties.
- Set priorities and goals in consultation with senior management. Give direction and guidance to departmental staff as necessary.
- Develop and maintain collaborative relationships with physicians, hospital leaders and employees.
- Perform other reasonably related business/job duties as assigned.
Education / Experience Requirements:
Graduate of accredited Bachelor’s degree program desired; Master’s Degree in Nursing with experience in Healthcare Quality and Outcomes Management is preferred.
At least 10 years of total relevant experience including at least:
- Three to five years of clinical hospital/hospital operations experience.
- Five or more years of hospital Performance Improvement and Risk Management experience.
- Three or more years of management experience in directing a complex hospital-wide Performance Improvement program.
- Experience with regulatory survey preparation and coordination
- Previous experience with Joint Commission Standards and Regulatory Compliance of other Agencies
- Detailed knowledge of Risk Management and Health Care Compliance Principles
Certificates, Licenses and Registrations:
- Certified Professional in Healthcare Quality preferred.
- Certified Professional in Healthcare Risk Management preferred.
- Six Sigma certification desired.
- Current California RN license desired.
Knowledge, Skills and Abilities Required:
- Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially regarding activities impacting patient or employee safety or security.
- Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles.
- Advanced knowledge of the Performance Improvement and risk reduction/avoidance philosophy, methodology, tools and techniques.
- Working knowledge of all regulatory compliance impacting Quality and Risk Management programs.
- Advanced knowledge of management principles, processes and procedures.
- Excellent interpersonal relationship skills at all levels of the organization.
- Verbal and written communication skills.
- Skill in planning, organizing and delegating departmental responsibilities.
- Skill in coaching, counseling, developing others and team facilitation.
- Ability to analyze and solve problems.
- Database management and program development.
This position description should not be construed to imply that these requirements are the exclusive standards of the position. Candidates will follow any other instructions, and perform any other related duties, as may be required. This position description is not to be construed as a contract for employment.
Paladin Healthcare does not discriminate on the basis of race, color, national and ethnic origin, sex, marital status, religion, or disability.