SUMMARY: Provide direction, leadership and coordination in all areas involving quality, risk management, patient safety, infection prevention and compliance. Develops strategic plans and policies for improved quality throughout Wilson Health and works with staff to ensure compliance with regulatory agencies. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. Develops goals and objectives for the Quality/ Risk Management Department and its components. Coordinate and oversee hospital QAPI Plan development, review, revision, and implementation. Prepare agenda and all pertinent quality improvement and risk management information to be presented to the Quality Improvement Council of the Board of Trustees. Coordinate and manage all quality reporting, ie. Qnet core measures, anthem scorecard, leapfrog, ODH Annual Hospital Registration, AHA Annual Survey, OHA Hospital Information/Innovation Network (HIIN) etc. Expert who provides consultation, counsel and guidance to professional staff within the department. Serves as Wilson Health patient safety officer. Serves as Wilson Health risk manager, includes WHMG. Serves as Wilson Health Compliance Officer Develops, coordinates, and administers hospital wide systems for risk identification, investigation and reduction, maintains statistics, ensures that pertinent patient data relative to claims is accurate, available and secure. Coordinates preparation for announced and unannounced accreditation or CMS surveys.
Develop, review and revise policies and procedures related to Quality/Risk Management and Patient Safety. Identifies through the analysis process a summary of issues and/or policies that have the potential to negatively impact clinical outcomes and/or the delivery of quality healthcare. Reports potential claims to carriers, review patient/family/physician complaints for liability risk and resolution. Manages and oversees the incident reporting system for all areas of Wilson Health. Log and trend incident reports, identify and address problems and/or patterns that emerge from this review. Provide support for all quality improvement/risk management activities within the hospital. Oversee and coordinate use of historical data in the MIDAS Quality/Risk System. Coordinates the improvement activities for successful accrediting, licensing, and certification surveys. Oversees the maintenance of the hospital administration policy manual. Develop department budget for staffing and capital expenses and ensure that the department operates within allocated funds. SUPERVISORY RESPONSIBILITIES:
Supervises employees in Quality/Risk Management and Infection Prevention. Responsible for the overall direction, coordination, and evaluation of the department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. EDUCATION and/or EXPERIENCE:
Active Registered Nurse license in the State of Ohio is required. Minimum requirement of a Bachelor's degree in Nursing, Master's degree preferred. Previous Quality/Risk Management Director experience required in a healthcare setting. Certification in Risk Management or Healthcare Quality obtained within 2 years of hire if not present. LANGUAGE SKILLS:
Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries and complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or board of directors. Ability to effectively present information to top management, public groups, and/or boards of directors. This would include the following age groups: pediatric, young-middle aged adult and geriatric. REASONING ABILITY:
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
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