Director Of Quality & Risk

Description

Position Summary:

The Director of Quality and Risk reports to the Chief Medical Officer and is responsible for 

compliance, quality, risk management and policy development in accordance with Mid-Valley 

Hospital and Clinic policies. The Quality Director will reflect the mission, vision and value 

statements of MVH and Clinic in both the hospital and clinic and the communities that we serve.

Position Competencies

• Project      Management and Planning
• Patient      Privacy
• Ethical      Conduct
• Flexible      Leadership Style
• Critical      Thinking / Decision Making
• Communications Proficiency
• Performance Management
• Personal      Effectiveness/Credibility and Trust
• Complex Problem      Solving/Analysis
• Strategic Thinking and Mindset
• Technical Capacity
• Desktop IT and EHR System
• Hospital and Clinic licensure, certification, and      accreditation
• District-wide management systems and reporting;
• All facilities planning and construction,      including various bidding and statutory requirements relating to      construction, maintenance, architects, and engineers

Essential Job Functions

· Develop, implement and oversee quality improvement to ensure delivery of the highest 

quality patient care, optimal patient flow, provider productivity and continuity of care. 

· Develop a conceptual framework for quality measurement and improvement activities 

across clinic sites. Summarize findings in the annual Quality Improvement (QI) Plan. 

· Work with CEO, COO, CFO, CMO, as well as members of Management to develop and ensure the implementation of policies to minimize risk within the organization. 

· Manage and oversee the Infection Control/EE Health Nurse and Education Coordinator.  

· Coordinate with the Cerner and EMR Super User to develop audit systems, 

perform data analysis and prepare reports related to measuring objectives and tracking 

outcomes as required by grants, contracts or MVH need. Analyze and report data, as 

required, in conjunction with the QI Reporting calendar and for continued recognition 

through NHSN, DOH and ACO activities. 

· Participate in quality components of DNV, DOH, CDC and Accountable Care Organization 

· Work with the CMO to develop new or update existing clinical outcome measures, protocols, policies and procedures to ensure compliance with policies through a peer review process. 

· Engages in the planning and implementation of the Corporate Compliance Program, 

including risk management reduction, which includes ensuring compliance with MVH policies and procedures as well as health, safety and regulatory requirements including HIPAA, OSHA, and DNV. 

· Investigate and act, in conjunction with COO, on matters related to compliance, including coordinate internal investigations and any resulting corrective action with all departments, contracted vendors, etc. 

· Develop and review policies and programs that encourage managers and employees to report suspected fraud or other improprieties. 

· Participate in long-range planning including the evaluation of patient satisfaction, current services and programs to increase, and market services to the community and to position MVH for change and growth. 

• Ensure that the responsibilities,      authorities, and accountability of all direct subordinates are defined and      understood.
• Accesses      Private Health Information (PHI) as needed to provide and promote high quality      health care and to protect the public's health and well-being.
• Ensures      compliance with all State and Federal Regulations.
• Directs      and supports performance improvement activities for the hospital. 
• Supports      and maintains a culture of safety and quality.
• Maintain      responsibility for other duties as assigned.

Educational Background and Experience

Minimum Education:

Nursing/Health related degree and current licensure as   applicable in nursing, public health or equivalent

Required Licensure / Certifications:

Current State of Washington licensure as an RN or   equivalent experience in quality management, utilization or risk management   areas or equivalent combination of education and experience. 

Required Experience:

3 or more years of related work experience in quality   management, utilization or risk management areas or equivalent combination of   education and experience.  .

Preferred Qualifications:

5 years as a Quality Director in a Hospital