Director of Quality and Risk

Overview

NeproPsychiatric Hospitals is seeking a Director of Quality and Risk at its Bremen location. This position plays a crucial role in ensuring high-quality, patient-centered care through the implementation and monitoring of quality assurance measures.

Responsibilities

• Implements and monitors quality goals and objectives to measure the organization’s processes and outcomes while administering programs that focus on improved outcomes of patient care or patient safety.
• Interacts with physicians, nurses, department managers, supervisors, and any/all other staff members to provide resource information and identify new opportunities to improve service and reduce costs.
• Generates effective quality-related policies and procedures for the department and hospital that ensures compliance with JC, OSHA, CDC, CMS and other county, state, and federal regulatory agencies.
• Prepares reports, presentations, and statistical data that go to the Quality Assurance and Performance Improvement Committee Meetings, facility's administration, and other committees as needed.
• Analyzes data to identify trends and resource utilization for use in optimizing compliance.
• Assists with the annual assessment of the quality control programs from the prior year activities.
• Investigates incidents within the facility and coordinates with the Corporate Quality team to complete the root cause analysis and develop action plans to prevent incidents in the future.
• Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving quality improvement.
• Prepares the agenda for the Quality Council Committee meetings and holds regularly scheduled meetings.
• Provides educational offerings for orientation and on-going in-services.
• Performs mortality reviews in conjunction with the mortality committee and holds regularly scheduled mortality committee meetings.
• Ensures all staff receive proper education on new or revised state and/or federal regulations or Joint Commission standards.
• Participates in Multi-disciplinary patient centered case conferences, as appropriate.
• Assesses and evaluates patients with infections and monitors patient outcomes on an ongoing basis.
• Initiates follow-up on employee/patient exposures to communicable diseases.
• Participates in root-cause analysis, sentinel events, adverse events and identifies trends as directed by regulation.
• Recommends ways to redesign systems for improvements if needed.
• Oversee Patient Advocacy program.
• Establishes/maintains good relationships with COO, CEO and DON’s and department leaders to promote a cooperative and constructive environment for improvement.
• Promote “Quality is everyone’s business” to gain support, understanding and ownership among staff.

Qualifications

• Bachelor's Degree in healthcare field or pertinent program required.
• Master's Degree preferred.
• 3+ years of relevant healthcare quality and risk management experience.
• Prior leadership experience preferred.
• Excellent verbal communication skills necessary in order present quality reports.
• Maintain effective contacts with a variety of Hospital Personnel.
• Professional knowledge of clinical practice, leadership, performance improvement and research statistics in order to conduct surveillance and prepare related reports at a level normally acquired through the completion of a Bachelor’s degree in related field.