Director of Quality and Risk Management

Director of Clinical Quality

Reporting to the Chief Nursing Officer, the Director of Clinical Quality is a key member of the hospital management team, and is responsible for overall hospital quality / performance improvement and monitoring of the organization. The position ensures the provision of differentiated quality and safety, patient-focused, outcomes based, and cost-effective medicine in the hospital setting. As such, the Clinical Quality Director's responsibilities will include, but are not limited to the following activities: Ensures processes are implemented to evaluate and identify opportunities for improvement in the provision of high quality, safe and resource effective medical care to its patients; implements Tenets Commitment to Quality initiative and assures goals are met; ensures processes are in place to ensure compliance with Quality and Performance Improvement and as applicable with Infection Control, Risk Management, Patient Safety, Peer Review, and Accreditation functions; monitors, in partnership with the medical staff, the measured outcomes of hospital clinical care activities, identifies opportunities for improvement, and leads clinical improvement activities to improve those measured outcomes; ensures documentation of the results of hospital wide, clinical quality activities; ensures hospital compliance with accreditation, licensing and regulatory agencies; assures that the Patient Safety Officer is responsible for providing the necessary leadership, training and support for performance of the plan by the employees' assuring and observing compliance with the policies and procedures outlined with full regard for the identification and reporting of incidents, potential hazards and other relevant information in a timely manner.

Qualifications

Minimum Education: Degree (Bachelors, Masters or Doctorate) in a health related field, with 5 years of relevant hospital management experience or other allied health professionals who have extensive hospital experience (>7 years, or other pertinent credentials) in the areas of responsibility will be considered.

Minimum Experience/Skills:

• Experience in quality/performance improvement, and as applicable in case management and other related areas of responsibility.
• Demonstrated knowledge of Performance Improvement
• Outcomes and Quality Management.
• As applicable, DCQI candidate also has demonstrated knowledge in the areas of Peer Review, Risk Management, Patient Safety, Infection Control Prevention and Reporting.
• Ability to interpret and process data in an analytical manner.
• Excellent communication (written and verbal) and presentation skills.
• Computer operational skills, understanding of statistics, spreadsheets and database systems.
• Current understanding of regulations as it relates to Joint Commission, State specific requirements, and Centers for Medicare & Medicaid Services (CMS).
• Demonstrated understanding of Quality Improvement Organization (QIO) guidelines/required processes and understanding of current trends in quality and other areas of responsibility as applicable.
• Ability to lead and coordinate activities of a diverse group of people.
• Ability to work with hospital team to motivate relevant constituencies to embrace change as required by Tenet's Commitment to Quality and other clinical initiatives.

License/Certificates/Credentials: None

Physical Demands:

• Prolonged, extensive or considerable standing/walking
• Lifts, positions, pushes up to 50 pounds.
• Manual dexterity and mobility.

Vision Requirements: Ability to adjust vision sufficiently to perform position accountabilities.

Working Conditions:

• Subject to varying and unpredictable situations.
• Exposure to unpleasant elements (accidents, injuries, illness).
• Emergency and crisis situations.
• Subject to irregular hours.
• Occasional pressure due to multiple calls and inquiries.