Director Of Quality And Risk Management

Position Summary: Plans and directs both the Quality and Risk Management Programs for the Satanta District Hospital, Clinics, and LTCU. Responsible for writing and editing the Quality Assurance Performance Improvement (QAPI) Plan and the Risk Management Plan annually and as necessary to keep the hospital, clinics and LTCU in compliance with all state laws and regulations. Responsible for documentation and retention of all records pertaining to Risk Management activities and Quality communications as dictated by federal and state laws and regulations. Develops teams to address the latest quality initiatives that will keep the hospital engaged and moving forward. Encourages integration of Risk Management issues into the quality program to help identify gaps in care and maintain safety for our patients, staff, and visitors. Familiar with State and Federal regulations and guidelines as they pertain to hospital Risk Management and quality programs.

Qualifications: Previous experience in clinical healthcare including direct experience in Quality Assurance and Performance Improvement (QAPI) and the development and maintenance of a Risk Management Program. Bachelor's degree is preferred. Must be licensed/registered and in good standing as required in a state where employed.

Duties:

• Plans and implements the QAPI and Risk Management programs to meet the needs of the hospital. Evaluates and monitors both programs and effects changes as necessary to keep the hospital, clinics and LTCU in compliance with all laws and regulations.

• Monitors and ensures facility wide compliance with the laws, regulations, policies and standard of Quality patient care.

• Directs the preparation and maintenance of department reports. Compiles statistical data and writes narrative reports summarizing QAPI and Risk Management activities.

• Prepares QAPI and Risk Management reports for Administration, the Medical Staff and Board of Directors on a quarterly basis.

• Participates in hospital/medical staff committee meetings. Attends and serves on the following committees: Safety/Infection Control, Pharmacy and Therapeutics, Medical Staff, Utilization Review, and Managers meetings.

• Prepares and directs the QAPI and Risk Management Meetings and maintains documentation of the outcome of the committee meetings.

• Consults with and advises committees on matters pertaining to QAPI and Risk Management.

• Develops goals for QAPI and Risk Management and establishes and implements policies and procedures for the departments.

• Develops, monitors, and implements the Quality Plan. Evaluates the effectiveness of the plan and changes the plan to meet the standards of Quality care. The plan will be reviewed annually and is sent to the Administrator, Medical Staff, and the Board of Directors for approval.

• Develops and recommends both department budgets and assures that the departments operate within that budget.

• Provides education to the department managers and the medical staff annually and as needed.

• Provides education on Quality and Risk Management to the staff on hire and annually as needed.

• Offers detailed education on matters pertaining to QAPI activities and assists them with understanding their responsibility for reporting.

• Prepares reports for the State Risk Manager each quarter and provides the Risk Management Plan for approval on an annual basis.

• Submits reports of Abuse, Neglect & Exploitation to the state in a timely fashion.

• Maintains professional growth and development through seminars, workshops, and professional affiliations.

Working Conditions:

• Handles emergency or crisis situations.
• Subject to numerous interruptions
• Normally work in an office environment.