Director of Performance Improvm/Risk Mgr

Our Director of Performance Improvement and Risk Management will:

Serve as a member of the Executive Team and on facility committees as requested. Interpret and implement corporate and facility policies and procedures in accordance with law and regulation.  Advise and assist management on risk management, regulatory, performance improvement and compliance issues.  Serve on a rotating basis as Administrator on Call.

Review and recommend PI and RM policies, procedures and processes.  Define required clinical data sets in conjunction with the Medical Staff and clinical leaders.

Implement performance improvement program.   Set expectations, develop plans and manage processes to measure, assess, and improve the quality of the organization’s management, clinical and support activities. Measure, analyze and manage variation in the performance of defined processes that affect patient safety. Provide quarterly performance report to Governing Board.

Develop and implement Risk Management program. Lead the hospital’s compliance program in conjunction with the corporate compliance officer.  Report risk management data and issues to corporate management. Lead sentinel and critical event analysis.

Direct compliance with laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of the various other accrediting and approval agencies.  Lead survey preparation, site visits and follow-up.  Create and administer systems for ongoing regulatory compliance. Direct policy and procedure development in accordance with laws and regulations.