Position Summary: The Director of Quality and Risk is responsible for directing and overseeing quality improvement, compliance, and risk management processes and initiatives in collaboration with the organization’s directors and managers, medical staff, CEO, and governing board. The director is responsible for maintaining a systematic, continuous team-based approach to quality and performance within the organization. The director develops, coordinates, implements, and monitors all aspects of the Health District’s quality management and performance improvement activities using constructive leadership skills to assist the organization in fulfilling its mission and meeting established annual and long-term objectives. In addition, the director develops and oversees Medical Staff Services. This position reports to the Chief Executive Officer (CEO) and the SCHHC Governing Board.

Responsibilities & Essential Functions: (This list does not include all the duties that may be assigned.)
– Identifies, assesses, and prioritizes facilities in the areas of risk, survey preparedness, and clinical programming.
– Assists facility staff in coordinating the investigation, processing, and defense of complaints for accrediting bodies, regulatory agencies, and MCOs.
– Monitors the timely submission and trending of required reporting.
– Completes departmental reviews to assist with survey preparation and follow-up, and completes internal quality, risk, and compliance audits.
– Contributes to human resource education and training needs regarding enterprise-wide compliance, quality, and risk.
– Coordinates and oversees the Health District Quality Assurance and Performance Improvement Plan development, review, revision, and implementation. Coordinates and integrates QI plans and processes for individual services.
– Collaborates with the Executive Team, Leadership, and Medical Staff to develop and achieve quality goals for the organization in alignment with the hospital’s strategic objectives and goals.
– Facilitates Continuous Quality Improvement teams. Facilitates planning sessions as requested.
– Provides regular in-service training to enhance awareness of employees’ role in quality improvement. Disseminates information on HCAHPS and other Health District-related survey results, MIPS Quality, Advancing Care Information, and Improvement Activities Results.
– Conduct research regarding performance measurements.
– Assists with research, development, and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
– Coordinates the process of monitoring, measuring, and assessment of patient care and support systems to achieve high-quality, safe, cost-effective healthcare services.
– Provides oversight for quality management-related functions for all Southern Coos Hospital District facilities.
– Proactively maintains the organization in constant survey readiness.  Ensures the organization meets all accreditation and licensing requirements.
– Coordinates, facilitates, and integrates software & systems to capture end user (provider, medical assistants, and clinic staff) documentation related to evidence-based quality indicators, performance improvement initiatives, and advancing care information measures.
– Develops, educates, and trains staff and Providers on risk & quality applications, measurements, and areas of risk.
– Develops and monitors policies and procedures.
– Facilitates the development of and provides oversight of the operations of the medical staff services office.
– Facilitates the development of and provides oversight of the operations of infection control and employee health.

Marginal Functions: (Duties that may be customarily performed on the job but are not essential to the job’s central functions)
– Directing visitors to appropriate hospital areas.
– Share responsibility for keeping the unit neat, clean, and organized.

Skills, Knowledge, & Experience Requirements:
– Master of Science in Nursing or other relevant graduate degree is desired.
– Four years or more experience in Quality Management, PI role, licensure, survey, and credentialing process is desired.
– Three years supporting the use of clinical information systems is required.
– Knowledge of EHR systems is required.
– Experience with educating/teaching is required.
– Working knowledge of Regulatory Compliance is required.
– Experience with accreditation and regulatory audits is preferred.
– Certified Professional in Healthcare Quality (CPHQ) is preferred.
– Certified Professional in Healthcare Risk Management (CPHRM) is preferred.
– Certified in Healthcare Compliance (CHC) is preferred.
– Five years of clinical care experience is preferred.
– Strong interpersonal skills with a drive to provide exceptional service.
– Ability to maintain strict confidentiality.
– Attention to detail and organizational skills.
– Excellent oral and written communication, and computer proficiency specifically in Microsoft Office and online software.

Other Requirements:
•Pace: Must have the ability to pace work time during sudden demands.
•Emotional Stability: Must continually show a calm, reasonable demeanor when interacting with any fellow employees, medical staff, or patients.
Attention to Detail: Observes hospital isolation procedures. Always identifies the appropriate patient care processes and procedures aligned with the job position.
•Adaptable: Supports new initiatives and changes. Adjusts readily to shifting priorities. Learn new concepts and work methods. Remains positive, efficient, proactive, and productive when faced with change.
•Professionalism: Presents a positive image. Does not engage in gossip or talk negatively about coworkers, physicians, or patients with other employees or within hearing distance of internal or external customers. Attends in-service training and staff meetings as required. Engages in ongoing self and professional development.
•Technical Competence: Is considered a subject expert in his/her area(s) of responsibility. Can be consistently relied upon to actively listen to others share knowledge and provide accurate work application and consultation in specialty areas(s).
•Repetitive Movement: Use of computer keyboard. Bending, standing running equipment, and/or moving inventory, if applicable,
•Customer Focused: Meets or exceeds internal and external customers’ expectations and needs. Puts patients and their families at the center of all work activities. Responds in a timely manner to requests for help and provides services or information requested or finds someone who can.
•Teamwork: Gains teammates’ trust and support. Performs work in a way that makes it easier for others to perform theirs. Proactively identifies and resolves conflicts in order to build productive relationships. Accepts assignments in a positive manner. Creates and maintains positive working relationships.
•Problem-solving: Assumes responsibility for improving processes and systems. Engages in quality improvement efforts. Identifies problems, looks for causes, and proactively works for solutions. Learns from others and one’s own experiences to prevent problems from recurring.
•Respectful of Others: Uses a professional and respectful tone of voice and language at all times. Respects confidentiality or sensitive information about customers, employees or hospital business and discusses only with those individuals having a valid need to know. Maintains composure at all times.
•Accountable: Keeps commitments. Openly admits mistakes and takes responsibility for one’s own actions and decisions.
•Excellent Communicator: Proactively offers information on organization processes and procedures. Invites questions and comments. Speaks and writes clearly. Communicates respectfully. Open to feedback. Understands that electronic communication is one of the key means of communication at SCH and consistently reads and responds to email and other electronic media.
•Ethical: Meets a high standard of conduct, honesty, and integrity in all situations. Acts responsibly with sensitive and classified information. Respect patients’ and co-workers’ rights to confidentiality. Complies with all legal and regulatory compliance standards.

Operation of Equipment/Tools:
– Must be able to utilize phones, copiers, faxes, computers, and keyboards. Physical Hazards/Working Conditions:
– May be exposed to communicable diseases.
– May be exposed to bloodborne pathogens.
– May be exposed to constant interruptions.
– May be exposed to electric shock.
– Work takes the employee to all areas of the District.
– Frequent need for bending, standing, kneeling, crouching, and sitting.