Director, Quality, Risk Prevention and Accreditation

In a bustling cosmopolitan area surrounded by nature, Adventist Health Portland has been one of the area's leading healthcare providers since the 1800s. In partnership with OHSU, we are comprised of a 302-bed hospital, 11 medical offices, home care services, comprehensive cancer care and a vast scope of award-winning services located throughout East Portland and the surrounding areas. There are many outdoor adventures readily available, including carving the snow at North America's only year-round ski resort, hiking along the Columbia River Gorge or taking a day trip to the unmatched beauty of the Oregon coast.

This is a FT 1.0FTE position working onsite at our Adventist Health Portland hospital.  This is not a remote role. 

Salary Range- $140,000-208,000 (DOE)

Job Summary:

Maintains responsibility for Quality Management and Risk Prevention functions. Provides overall direction, development, implementation and integration of the Quality Management program which includes compliance with all the Joint Commission, Federal, State and local reporting requirements. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment. Leads, develops and deploys a comprehensive, highly reliable program across the continuum of care and implements the organization's vision of excellence in clinical and quality outcomes and patient safety. Establishes a structure that supports the organization through analytics, analysis and High Reliability Organization (HRO) safety initiatives such as Culture of Safety, Just Culture and others included in strategic directives. Works closely with the ministry leaders of quality, physician services, nursing leadership and homecare to champion communication, transparency, teamwork and a culture of safety. Supervises Infection Prevention program that is responsible for surveillance, analysis, interpretation and reporting of Hospital Acquired Infections (HAI) and infection prevention education.

Job Requirements:

Education and Work Experience:

• Bachelor's degree in a healthcare-related field, preferably Nursing, or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Previous leadership experience in a Quality & Risk Management department setting preferred.
• 7 years' clinical experience in acute care setting, or equivalent combinations of education/related experience: Preferred
• 7 years' healthcare quality leadership, project management/lean or sigma training and experience building or leading a High Reliability Organization (HRO): Preferred
• 5 years' leadership experience: Preferred

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of Oregon: Required
• Certified Professional in Healthcare Quality (CPHQ): Required
• Basic Life Support (BLS OR HS-BLS OR RQI BLS) certification: Required

Essential Functions:

• Champions clinical quality performance and patient safety, to meet established patient safety, quality and compliance goals. Directs the development of programs and processes related to Quality Management. Provides education to all quality leadership and executives. Facilitates organization wide transition to a High Reliability Organization through development of policies, standards, indicators, implementation and evaluation techniques. Develops policies and procedures, monitors performance, develops and reviews metrics, assesses and prioritizes risk, and reports results to leadership. Serves as a resource to quality teams, medical staff and executives.
• Develops and maintains the quality and patient safety plans for the organization. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives. Supports organization in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees
• Collaborates with analytics teams to develop and maintain quality metrics that meet required reporting such as Electronic Clinical Quality Measures (eCQM) and more. Works with analytic team and our Electronic Health Record (EHR) vendor to apply meaningful analysis and process improvement. Knowledge leader for Value-Based Purchasing (VBP), Healthcare Associated Infection (HAI), readmissions, mortality and more for any clinical performance programs such as government or commercial pay for performance. Supports quality metrics for contracted services as needed.
• Evaluates various attributes of health care, such as safety, cost, place, treatment, and benefits as compared with standard results, for the purpose of making recommendations for improvement using standardized Perf