Director of Quality and Risk Management
Department: Quality Management
Schedule: Full-time
Shift: Day shift
Hours: 8-5
Job Code:
Job Details: - RN Licensure Required
- Experience is required

The Director of Quality and Risk Management is responsible for coordinating organization-wide performance improvement, ensuring regulatory compliance, and promoting patient safety. The position, under the leadership of the Vice President of Patient Care Services, will direct the PI activities within Quality and Patient Safety. This position plans, directs, and coordinates programs designed to enhance patient care, operational efficiency, and clinical effectiveness.

Key Roles

-Development and implementation of Medical Staff performance measurement tool(s)
-Participation and management of a Joint Commission preparedness work plan
-Continued proliferation of a metric-driven culture
-Under the direction of the VP of Patient Care Services, consults with legal counsel on matters involving hospital professional liability and oversees litigation matters

Key Responsibilities
• Directs, develops, and continuously improves the Hospital-wide Performance Improvement Program to ensure program effectiveness, goal achievement, state of the art practices, and regulatory compliance
• Coordinates the ongoing monitoring and evaluation activities of medical department and hospital departments
• Consults to all medical and hospital departments in development of performance improvement plans, initiatives, and measurement strategies
• Facilitates staff development activities related to quality improvement and new/revised standards in an interdisciplinary fashion in collaboration with medical and hospital departments
• Maintains knowledge of current performance improvement practices and incorporates them into the PI program; remains current on industry trends in performance improvement and quality metrics
• Oversees, plans, organizes, and directs development and revision of organization-wide standards in relation to internal and external standards
• Oversees, conducts, and coordinates development and review of quality assessment and improvement activities and prepares summary reports as required
• Participates in medical and hospital department committees necessary to problem solve and coordinate the provision of services to lead to better clinical performance
• Keeps abreast of appropriate regulatory agency requirements related to quality improvement
• Ensures efficiency and effectiveness of data collection, analysis, and reporting to drive performance improvement processes
- Oversight responsibility for all regulatory body surveys, i.e., JCAHO, State Licensing Review, HCFA (CMS) Validation surveys.
- Maintains oversight responsibility for all performance improvement activities conducted throughout the institution.
- Is responsible for the implementation, coordination and direction of resource utilization management and case management activities.
- Maintains oversight responsibility for medical necessity reviews, appropriateness of levels of care by applying nationally recognized criteria.

- Manages loss control and risk/claims including:
-Monitors incidents and claims reporting system
-Coordinates with carrier the investigation and defense of all claims and lawsuits
-Coordinates and oversees medical peer- review and institutional committees on issues related to standards of care
- Oversees and manages a formal program for ongoing education for all hospital staff
- Responds to crisis situations that have risk management implications and assist staff with problem solving.
- Supervises all professional and support staff in risk management department
The Ideal Candidate
Coffee Regional Medical Center seeks a Director of Quality and Risk Management who brings a mix of experience, talent, style and values that will enable him/her to succeed in a complex and diverse environment and who is sought out as an expert to provide advice or solutions in this high profile area. An ideal candidate will also bring the following professional experience and personal qualities to this important role:
-Minimum of 5 years leadership experience in Quality and Risk Management in a hospital
-Master’s Degree in nursing, public health, healthcare administration, or related field
-Current RN licensure
-Certified Professional in Healthcare Quality (CPHQ) preferred
-Lean/Six Sigma Certification preferred
-Exceptional critical thinking abilities, quantitative analytical skills and well-versed in report design and presentation development
-Strong facility with Microsoft Office applications, especially Excel