Admin Director of Quality & Risk Man

Job Description

Job Description

Coffee Regional Medical Center

Administrative Director of Quality & Risk Management

POSITION SUMMARY

The Admin Director of Quality & Risk Management oversees and enhances the organization's quality assurance and risk management frameworks. This role ensures compliance with regulatory standards and internal policies to safeguard organizational integrity and operational excellence. The director will lead cross-functional teams to identify, assess, and mitigate risks while promoting a culture of continuous improvement and accountability. They will develop strategic initiatives to improve quality outcomes and reduce potential liabilities, aligning with the organization's mission and goals. This role ensures compliance with regulatory standards and internal policies to safeguard organizational integrity and operational excellence. Ultimately, this position drives the integration of quality and risk management practices into all operational areas to support sustainable growth and mitigate risks while promoting a culture of continuous improvement and accountability.

OVERVIEW

This position provides strategic leadership to ensure the delivery of safe, high-quality, and compliant services across the organization. This role is responsible for overseeing performance improvement initiatives, risk mitigation efforts, regulatory compliance, infection prevention and control programs, and patient safety programs.

QUALIFICATIONS

A. Position standards

• Excellent customer service skills.

• Reads and understands the English language.

• Ability to think critically and analytically with little or no supervision.

• Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.

• Ability to process information and prioritize.

• Possesses exceptional verbal and written communication skills.

• Possesses independent work habits, is self-reliant and self-directed.

• Ability to learn, adapt, and change as required by the job functions.

• Ability to maintain absolute confidentiality of material and information accessed and reviewed.

• Computer proficiency, including Microsoft Office applications.

• Ability to move freely, reach, bend, and complete light lifting.

• Ability to use good body mechanics while performing daily job functions and the ability to follow specific OSHA guidelines.

• Ability to maintain attendance to meet standard job practices.

• Serves as a role model to staff throughout the organization.

B. Education

• Bachelor’s degree in Healthcare Administration, Nursing, Respiratory Therapy, Public Health, or a related healthcare field required.

• Master's degree in nursing, public health, business, healthcare administration, or related field

• Consideration will be given to candidates with a significant clinical background combined with experience in accreditation, regulatory compliance, or quality/risk management.

C. Licensure Preferred

• Certified Professional in Healthcare Quality (CPHQ)

• Certified Professional in Healthcare Risk Management (CPHRM)

D. Experience

• 5 years of experience in Quality and Risk Management or Healthcare Leadership.

E. Interpersonal skills

F. Essential technical/motor skills

G. Essential physical requirements

H. Essential mental requirements

I. Essential sensory requirements

J. Other

K. Equipment used

OTHER QUALIFICATIONS

A. Exposure to hazards (body fluid exposure level)

• Level II

B. Age of Patient Populations Served

• No physical patient contact.

JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDS

• Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.

• Manages human resources to ensure quality services and promotes positive employee relationships as evidenced by:

o Consistently and fairly implements HR policies.

o Follows progressive disciplinary action process, or oversees subordinates in doing so, in order to maintain productivity and performance standards.

o Provides supporting investigatory documentation to validate final outcomes.

o Collaborates with HR on the recruitment and selection of qualified employment candidates, following all policies, guidelines, and applicable laws.

o Develops performance goals/objectives with each staff member to promote maximum productivity, proficiency, and professional growth, as evidenced by written goals on performance appraisals.

o Effectively communicates departmental, organizational, and industrial information to staff.

o Employee performance appraisals are completed thoroughly and submitted on time.

o Maintains effective and appropriate staffing by monitoring employee turnover, overtime, and absenteeism.

o Is recognized as a positive role model.

• Accurately identifies real/potential problems affecting service and implements solutions with follow-through and communication as evidenced by:

o Responds to reported problems/complaints based on urgency.

o Fully documents complaints, investigative findings, and follow-up (i.e. letters, reports)

o If corrective action is identified, a plan is implemented within the time-frame specified and evaluated for effectiveness.

o Identifies potential for problems within existing systems by direct observation or analysis of date.

• Develops, implements, and evaluates an ongoing service program that ensure quality programs consistent with the hospital mission as evidenced by:

o Performs/participates in assessment of programs.

o Based on assessment, develops program proposals.

o Implements programs within defined parameters.

o Establishes systems to measure effectiveness of the new programs.

o Evaluates ongoing programs as prescribed in the current systems.

• Monitors compliance with regulatory, accrediting, and organizational policies for services and environmental and personnel safety as evidenced by:

o Establishes systems to evaluate compliance with regulatory agencies, hospital policy and procedure and environmental safety.

o Monitors compliance with certifications/mandatory educational program attendance by QI, reports, meetings, minutes and observation.

• Is responsible for the operational excellence and ensures that department(s) deliver quality services as evidenced by:

o Manages all activities so that quality services are provided in an efficient and effective manner.

o Services provided meet all applicable regulatory requirements.

o Maintains an effective quality improvement program, as evidenced by reports.

o Quality improvement programs meet DNV and other regulatory agency requirements, as evidenced by review.

• Is responsible for the fiscal management of department(s) and ensures the proper utilization of the organization's financial resources as evidenced by:

o Budget is accurate, complete and submitted by due date.

o Monitors budget expenditures as reflected in accurate analysis.

o Develops, prioritizes and defends a capital equipment budget.

o Effectively utilizes resources within an established budget and notifies vice president of all variances anticipated or accrued to maintain department services.

o Recommends ways to reduce expenditures and enhance revenues without compromising quality of services.

o Implements methods for inventory control that minimizes waste and emergency orders.

o Works closely with billing department to ensure accuracy if applies to department.

• Seeks new program strategies and enhancements that will expand or improve services as evidenced by:

o Explores required resources and reviews impact.

o Initiates program proposals and submits for consideration.

o Actively leads service, departmental and organizational-wide committees.

• Job Specific Duties

o Directs, develops, and continuously improves the Hospital-wide Performance Improvement Program to ensure program effectiveness, goal achievement, state of the art practices, and regulatory compliance through the organizational structure.

o Participates in the Quality Assurance and Patient Care Committee of the Board of Trustees, including Board Quality, Clinical Services Committees, Medical Board monitoring committees, medical department and hospital department meetings

o Coordinates the ongoing monitoring and evaluation activities of medical department and hospital departments.

o Consults to all medical and hospital departments in development of performance improvement plans, initiatives, and measurement strategies.

o Facilitates staff development activities related to quality improvement and new/revised standards in an interdisciplinary fashion in collaboration with medical and hospital departments.

o Maintains knowledge of current performance improvement practices and incorporates them into the PI program; remains current on industry trends in performance improvement and quality metrics.

o Oversees, plans, organizes, and directs development and revision of organization-wide standards in relation to internal and external standards.

o Oversees, conducts, and coordinates development and review of quality assessment and improvement activities and prepares summary reports as required.

o Participates in medical and hospital department committees necessary to problem solve and coordinate the provision of services to lead to better clinical performance.

o Keeps abreast of appropriate regulatory agency requirements related to quality improvement.

o Support survey readiness activities, mock surveys, and staff preparation.

o Ensures efficiency and effectiveness of data collection, analysis, and reporting to drive performance improvement processes.

o Serves as the hospital accreditation leader - prepares and maintains accreditation for the organization.

o Addresses risk and legal issues concerning quality of care and patient safety issues.

o Coordinate activities related to Value-Based Purchasing, Readmissions, HCAPHS, etc

o Coordinate Leapfrog and GHA programs and data related to quality.

o Conduct and lead root cause analyses (RCA) and coordinate corrective and preventive action plans.

o Manages the incident reporting system.

o Identifies and evaluates potential liability claims (malpractice and other)

o Provide education and training on performance improvement, safety and risk management programs, and HIPAA compliance programs.

o Provide leadership and oversight of the Infection Prevention and Control Program, ensuring compliance with CDC guidelines, CMS requirements, and accreditation standards.

EDUCATION AND COMPETENCY

• Attends all mandatory and department-specific education and training programs as required.

• Attends all required education and training and can describe his/her responsibilities related to department safety and specific job related hazards.

• Has met all required competencies for the evaluation period as evidenced by job specific competency evaluations…