Director of Quality & Risk
Company: Encompass Health
Location: Cincinnati
Posted on: April 17, 2024
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Job Description:
The Quality/Risk Director is responsible for an environment and
culture that enables the hospital to fulfill its mission by meeting
or exceeding goals, conveying the mission to all staff,
facilitating staff accountability for performance, and motivating
staff to improve performance. This position manages, directs, and
plans all aspects of Quality and Risk Management. The Director is
responsible for hospital-wide quality management program and works
with hospital administration, departments, and the medical staff to
monitor and evaluate the quality of delivery of patient care
services within the hospital. They will have access to all medical
records for the hospital; will ensure proper compliance with
regulatory agencies, accrediting bodies, and Home Office and
hospital policies and procedures; and will work to develop,
implement, and maintain quality assessment and improvement programs
within the hospital. RESPONSIBILITIES AND TASKS Assesses compliance
with federal, state, and industry regulatory and accreditation
standards.o Facilitates processes to remediate and/or maintain
compliance.o Provides organizational education related to the
regulations and standards.o Compiles data in usable formats for
analysis against appropriate benchmarks, using current statistical
tools and techniques in an effort to identify improvement
opportunities.o Prepares and submits timely, statistically correct,
complete reports of risk management and quality information to the
appropriate hospital, regional, corporate, or external agency.o
Successfully completes annual skills competency as determined by
the hospital based on new responsibilities, specialized equipment,
high risk/problem prone/or low volume procedures including
emergency response techniques. All assigned training must be
completed by required completion date. Coordinates
local/state/federal/accreditation surveys and associated action
plans and assessments.o Submits corrective action plans and
assessments (i.e., TJC PPR) to regulatory and accrediting bodies
within required timeframe.o Oversees oversight of corrective action
plan through ongoing monitoring.o Maintains appropriate records and
documentation of Quality Council, MEC, and Governing Body
activities including minutes, supporting data, logs, and all
related documents in accordance with state and federal law.
Facilitates committees, teams, and plan documentation for
performance improvement.o Ensures that the following PI teams are
in place: falls PI committee, FMEA, and others per hospital
priorities.o Mentors others for the leader and facilitator role in
the performance improvement process.o Encourages others to serve as
PI team leaders and facilitators.o Ensures updates and maintenance
of hospital plans is completed (for example Plan for the Provision
of Care/Scope of Services, Leadership, Information Management,
Utilization Review, Infection Control, Performance Improvement and
Patient Safety). Manages implementation of hospital policies and
applicable corporate (e.g., Compliance) policies.o Coordinates the
review, revision, development, approval, and implementation of
hospital specific policies.o Coordinates the implementation of
corporate policies applicable to the hospital.o Acts as an
organizational liaison with the CEO and Corporate Compliance to
ensure implementation of the Standards of Business Conduct and all
applicable compliance policies. Collaborates with other departments
to coordinate care and resolve customer concerns or complaints.o
Oversees complaint process including complaint investigation;
verbal and written complaint follow-up; corrective action planning;
and maintenance of complaint log.o Resolves issues promptly as
outlined in the Corporate Patient Complaint/Grievance Policy.o
Ensures verbal/written follow-up occurs within required timeframe
and in accord with Corporate Risk Management policy. Coordinates
all RCA (root cause analysis) and sentinel event report development
and submission.o Submits reports to required local, state, federal
and accreditation agencies related to sentinel events and mortality
as required by local/state/federal jurisdiction and/or
accreditation agencies. Shares Patient Satisfaction data with
leadership/staff monthly (min.) and coordinates improvement.o
Identifies opportunities for improvement and coordinates the
organizational efforts to improve patient satisfaction. Oversees
risk management activities including completion of
reports/claims/plans.o Completes incident reports, notice of
potential claims, corrective action planning and incident reporting
to Corporate Risk Manager.o Completes monthly online reporting to
Corporate Risk Management within required timeframe. Uses a variety
of applications to perform technical analyses and planning.o
Identifies improvement opportunities, generates reports, research
issues, identifies resources, and accesses external databases.o
Maintains familiarity with company applications including but not
limited to PatCom, UDS, ORYX, and Press Ganey Organizes, plans, and
manages time effectively to complete assignments. Meets position
requirements and performs essential functions. Qualifications
License or Certification: Licensed or certified according to
individual state requirement. Minimum Qualifications:
Keywords: Encompass Health, Covington , Director of Quality & Risk, Executive , Cincinnati, Kentucky
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