Director of Quality

7 days ago

Mayfield, United States Theron Solutions Full time

Minimum Education

  • Bachelor’s degree in Nursing - Required
  • Master's degree in Nursing or Business/Healthcare related field - Preferred
  • Certification in Risk Management through a nationally recognized program meeting industry standards - Preferred


Required Skills

  • Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Computer skills required. Strong understanding of: Process Review; Root Cause Analysis; Department of Health and Joint Commission requirements familiarity.
  • Basic Life Support (BLS) American Heart Association must be obtained within 90 days of employment, if not current upon hire
  • License: Current KY or Multi-State RN licensure. CPHQ certification required within 1 year of employment


Minimum Work Experience

  • Five (5) years of healthcare experience as RN and two years’ experience in quality/clinical nursing leadership. - Preferred
  • Five (5) years of experience in healthcare risk management and accreditation. Experience in the insurance industry is supportive to the skill set of the risk manager. - Preferred
  • Three (3) years of experience in direct patient care with some experience in critical care. - Preferred


ESSENTIAL FUNCTIONS

  • Develops and implements departmental goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements/objectives of the organization.
  • Directs and evaluates departmental operations, including patient care delivery, information technologies, service level determination, and complaint management, to achieve performance and quality control objectives.
  • Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary actions, and continuing education initiatives.
  • Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates incompliance with allocated funding. Coordinates and directs internal/external audits.
  • Creates and fosters an environment that encourages professional growth.
  • Integrates evidence-based practices into operations and clinical protocols.
  • Provides prompt notification to appropriate parties upon receipt of claim or lawsuit. Assist HSC Risk, leadership and external counsel in defense of the claims as instructed.
  • Provides leadership, counsel, and support in areas of Risk Management.
  • Escalates significant risk issues with urgency.
  • Collaborates with site patient safety/quality improvement and patient experience leadership to respond to patient grievances. Uses decision making ability to analyze and recommend disposition strategies. Oversee and direct occurrence reporting process for site. Ensures timely data entry of reports received. Completes necessary trend analysis of occurrence reports.
  • Collects data for risk exposures and provides feedback to the involved departments. Ensure identified risk management strategies are undertaken by affected areas.
  • Develops a safety culture where reporting is encouraged and use of SIM reporting system is monitored, with interventions to address issues as needed.
  • Provide in-service education on risk management topics, both standard basic education and complex focused topics as needed and/or requested.
  • Provide statistical analysis for review by appropriate committees as requested.
  • Create and implement new programs to foster a culture of safety and safe environment for patients, visitors, and staff.
  • Coordinate and oversee the development of comprehensive accreditation improvement initiatives to establish compliance with regulatory agencies.
  • Coordinate and ensure the implementation of organization-wide regulatory compliance activities with The Joint Commission, CMS, and other regulatory agencies.
  • Facilitates the development of ongoing readiness action plans, assessments, and educational activities as appropriate.
  • Utilizing the standards and regulations from CMS and TJC, oversees concurrent monitors to determine if staff knowledge and clinical practice meet appropriate standards.
  • Coordinates risk reduction activity in the physical environment as specified within each Environment of Care(EOC) Management Plan.
  • Facilitate the organization’s Regulatory Committee.
  • Participates in interdisciplinary collaboration to measure and assess processes and outcomes, and proactively identify potential solutions with the multidisciplinary team and appropriate service line leaders and directors.


Equal Opportunity Employer:


Our client is an Equal Opportunity Employer and Prohibits Discrimination and Harassment of Any Kind: We are committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at our client are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.

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