Director of Quality and Risk Management Full Time

DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure. Reporting to the Chief Nursing Officer DMC Main Campus assumes system management responsibility for multiple (2 or more) services, functions, or processes within the assigned specialty area. Specialty nursing areas include:
• Medical/Surgical
• Women’s Services
• Adult Central Campus
The position is broad in scope and functions within a matrix reporting structure. The role includes programmatic responsibilities in Nursing and Operations. Coordinates a cohesive approach to executing clinical strategies and patient care across the DMC organization, including performance excellence and quality outcomes. Translates data into practice.
Works collaboratively with clinical leadership to standardize nursing practice to deliver high quality clinical care, incorporating research and teaching activities. Cultivates and maintains professional relationships with primary customers of the clinical area(s) including medical directors, physicians, physician groups and patients to enhance customer service and to positively impact core clinical measures. Develops, implements, monitors and evaluates systems/initiatives/programs to facilitate performance/quality improvements in keeping with strategic objectives and regulatory requirements. Implements rapid quality improvement interventions and Lean methodologies. Understands the benefits of standardization and how to drive its implantation through the service line to improve quality, efficiency, patient, staff and physician satisfaction.
Provides input into the development and revision of organizational structure for function or service. Approves personnel actions, such as hires, fires and disciplines. Ensures the timely completion of performance appraisals. Specifically, the position identifies the need for policy development and/or revision, defines policies in collaboration with higher-level management input, goals and objectives. In collaboration with the executive senior leadership team and in cooperation with others in the hospital and DMC System, assists in developing and implementing current to intermediate goals and measures for areas of responsibility. Measures and assesses performance. Coordinates a cohesive approach to clinical strategies and patient care across the DMC organization including performance excellence and quality outcomes. Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and DMC policies.
Key Responsibilities in alignment with Nursing Practice (AONE Core Competencies):
*Adapted from the American Organization of Nurse Executive (AONE) Nurse Executive Competencies
Retaining great people at the facility
• Participates in workforce planning to ensure an adequate and competent workforce
Communication and Relationship Building
• Effectively communicates with all internal and external constituents, including staff, colleagues, and physicians
• Manages organizational relationships in a manner which builds mutual trust and respect. Addresses and manages conflict in a constructive and productive manner
• Develops, communicates and monitors performance expectations
• Demonstrates effective change management, able to serve as an organizational change agent
• Diversity
• Creates an environment which recognizes and values diversity
• Designs strategies that address the unique needs of a diverse workforce, patient population, and community
Engages staff and others in decision-making
• Promotes systems thinking as a value in the nursing organization
• Considers the impact of nursing decisions on the health care organization as a whole
Understands and articulates patient care standards reflected in federal and state regulation, TJC, the state Nurse Practice Act, and organizational policies and procedures
• Maintains knowledge of current nursing practice and roles and functions within nursing and other healthcare disciplines
• Ensures that nursing/clinical practice is consistent with current standards and current evidenced based practice
• Teaches and mentors others to routinely utilize evidenced based data and research
Academic Relationships
• Provides a supportive and stimulating learning environment for nursing students
• Participates in the academic community through advisory and collaborative efforts
Resource Management
• Demonstrates a comprehensive understanding of organizational revenue, expense performance and capital planning.
• Manages fiscal, human and material resources in a cost effective manner
Quality, Patient Safety and Risk Management
• Contributes to the development and implementation of the organization’s performance improvement program Supports the development and implementation of an organization-wide patient safety program
• Monitors and evaluates quality through public reported measure (i.e. core measures, nurse sensitive patient outcomes, infection control, etc.) in collaboration with the facility DCQI and ICP, as well as national resources.
• Designs safe clinical systems, processes, policies and procedures
• Ensures staff is clinically competent and trained on their role in patient safety, performance improvement, and risk management
• Identifies, mitigates and takes action to correct areas of risk/liability in patient care
• Facilitates facility level annual pressure ulcer prevalence and incidence study results with corrective action
Information management and technology
• Supports and embraces role in the adoption of EMR within facility
• Demonstrates basic competency in technology applications related to business and clinical functions
• Utilizes hospital database management, decision support, and expert system programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems
Monitors and evaluates service indicators in collaboration with related team members at the facility level.
• Actively facilitates Physician satisfaction survey, monitors results and collaborates with facility team members to develop and implement action plans
• Monitors and evaluates results of annual Employee Satisfaction Survey and collaborates with related team members to develop and implement action plans
• Garners resources to ensure employees provide the highest quality patient experience throughout the continuum of care.
Advocates for nursing
• Master’s degree in Nursing, Health Administration, Business, Public Health, management or related field required.
Academic degree in nursing required (Bachelor’s or Master’s degree).
Five years of progressive management experience in a hospital environment as an Associate Chief Nursing Officer or Nursing director of multiple, complex nursing departments.
Analytical ability to create solutions to difficult administrative, technical or human situations, to anticipate and resolve a broad range of issues and concerns on multiple, sometimes unrelated, topics, to determine the need for process development and refinement, to independently evaluate situations and outline ramifications of multiple solutions or options, to recommend goals for a function/area and understand when intervention in current work processes must occur to ensure successful delivery of service.
High level of communication and interpersonal skills for contacts with internal and external customers/stakeholders to obtain and interpret a variety of information based on knowledge of departmental practices, DMC policies and programs and specific technical and regulatory knowledge. conflict resolution skills must be exercised where policy issues are concerned both within the functional area and interdepartmentally. Ability to read, interpret and write technical materials.
Broad technical knowledge of the administration and operations of healthcare functions and facilities including human, legal, technological, fiscal and customer aspects of the delivery of care.
Project management skills including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological and fiscal resources to accomplish goals and objectives in a resourceful yet timely manner.
Ability to serve as role model and advocate for the professional discipline of nursing.
Facility: DMC Harper University/Hutzel Women's Hospital
Job Type: Full Time
Shift Type: Day
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.