Overview
Job Summary
This position is responsible for all quality, compliance, risk management, patient safety, and medical staff
credentialing activities within the hospital. It has primary responsibility for interfacing with the medical staff
in matters pertaining to the above, and for managing the relationship with the corporate departments
responsible for these functions at the system level.
Job Responsibilities
• Develops and implements strategy relating to matters of quality, outcomes and experience, and
for identifying and mitigating risks to the patient and/or staff. Creates and manages major
elements of the Strategic A3s relating to Right Care.
• Oversees all activities relating to complying with the requirements for hospital accreditation and
licensure. Interfaces directly with JCAHO, the Mississippi Department of Health, and CMS as
necessary.
• Oversees the hospital’s benchmarking programs. Is the hospital’s point of contact and manages
the hospital’s engagement with Leapfrog, Premier, Quest, and Vizient.
• Oversees the hospital’s response to, and resolution of grievances filed in the public domain.
• Administers the hospital’s adverse incident process. Oversees the investigation and evaluation of
incidents, including the taking of corrective actions as needed. Identifies trends and other factors
that may influence policy development.
• Oversees the discovery process in cases with the potential for claims against the hospital. Is
involved in all aspects including evaluation and assessment, the consideration of defense
strategies, and the recommending of settlements or other actions.
• Designs programs and oversees the orientation and education of staff in matters of quality,
regulatory compliance, patient safety, and patient experience.
• Is the primary liaison with the medical staff in matters of quality, regulatory compliance,
investigation of claims and actions, and patient experience. Is the hospital’s representative to the
Peer Review, and Quality Committees.
• Assists the medical staff office in matters relating to credentialing, the delineation of privileges, the
medical staff bylaws and rules and regulations, and the disciplinary process.
• Is the primary interface with the corporate departments responsible for quality, compliance, risk
management, and patient safety at the system level.
• Participates in community health activities including mortality review, planning for events
impacting the health status of the citizenry, and in the adoption and administration of regulations
affecting the hospital.
• Prepares and oversees the budget for the assigned areas of responsibility. Recommends
programs and expenditures that can influence outcomes, experience, and/or the mitigation of risk.
• Develops and administers policy relating to quality, compliance, risk management, patient safety
and patient experience.
Experience
Description Minimum Required Preferred/Desired
Five (5) years of clinical
experience as a registered nurse
or healthcare management with
previous experience in Quality,
Risk and/or Compliance
5 years' experience in quality, risk
or compliance; baccalaureate,
associate or diploma degree in a
health-related field, nursing
preferred; Certified Professional
in Healthcare Quality (CPHQ)
Education
Description Minimum Required Preferred/Desired
Completion of a baccalaureate,
associate or diploma degree in
health-related field
Baccalaureate degree - Nursing
preferred
Description Minimum Required Preferred/Desired
Knowledge of licensure and
accrediting requirements; ability
to communicate and work
effectively with medical staff,
department heads and
administration; excellent
organizational skills and problem
solving abilities
Licensure
Description Minimum Required Preferred/Desired
Registered Nurse