Director of Organizational Quality/Risk Management

Job Number 53108
Posted 3/7/2018
Account Sebasticook Valley Health
Department Quality Risk Management
Location Sebasticook Valley Hospital, ME 04967
Schedule Regular Full-time
Shift Day
Hours 8:00 am-5:00 pm
Job Details Summary
Provide oversight and direction for all aspects of organizational quality, performance improvement, regulatory, and risk management. Ensure documentation of all PI/QI activities; work with leadership to produce optimum departmental and organizational results to include alignment with EMHS quality initiatives as appropriate. Coordination of Medical Staff Quality Case Review process, initiate and develop programs and systems for The Joint Commission, State Licensing, other regulatory agencies as needed and coordinate risk management activities. Provide oversight and direction for Executive Administrative Assistant.

BSN Required
State of Maine RN license Five (5) years of leadership or project management experience in healthcare quality/performance improvement/risk management/utilization.
Previous experience in data collection and analysis, trend/pattern identification and presentation of information to different audiences. Proven commitment to continuous quality/performance improvement. In-depth knowledge of and management of regulatory agencies' requirements/onsite (State Licensing, The Joint Commission, OSHA, etc.). Ability to effectively work with Medical Staff and hospital wide staff consultatively on PI/RM/URM/Social Work issues. Familiarity with legal aspects related to Quality/PI, peer review, medical records, minutes, risk management, and other areas of functional responsibilities. Experience with program management for utilization management review/QIOs, and credentialing

Training: Working knowledge of Quality/Performance Improvement, State Licensing and Certification process, and Joint Commission Standards,
risk management and relevant legal aspects.

Job Responsibilities
Oversight, direction and management of the Quality/PI & RM Program (hospital wide/Medical Staff) consistent with PI/RM Plan.
Provides support and direction with the Risk Management process
Oversight and management of the AHRQ Patient Safety Survey
Oversight , direction and management of the Sentinel Event Process consistent with SE Plan
Ensuring SVH's ongoing preparedness for, participation in, response to, management of regulatory agencies' inspections and surveys (State Licensing, The Joint Commission, others as may be appropriate) for all departments of Sebasticook Valley Health.
Responsible for specific department budget maintenance.
Provide education/guidance to staff in areas of responsibilities.
Provides support for the patient experience surveys through AVATAR/Press Ganey
Provide ongoing reports/status updates to CEO and Board as per Plans.
Support of management of physician Case Review files
Provides major support to Environment of Care (EOC) for annual and semi-annual Safety Surveys
Provides leadership on hospital committees (Information Management and Compliance Team).
Manages all facets related to the State reporting of the Maine Health Data Organization (MHDO)Nursing Sensitive Measures
Provides consulting/leadership in areas of Quality /Performance Improvement (e.g. PFPCQS, HEN 2.0 etc.)
Resource in development of clinical policies.
Supports Patient Safety Initiatives by measuring and tracking compliance
Management of The Joint Commission updates and National Patient Safety Goals
Coordinates the Focused Risk Assessment for TJC as required
National Quality Forum
Oversight and submission of the annual Leapfrog Survey with the National Quality Forum updates
Oversight and management of the electronic Patient Relations & Incident Reporting
Support and facilitate open & non-punitive communication between healthcare
workers, patients, and families regarding clinical and environmental safety on
their unit and when interfacing with other units, groups, and individuals.
Support and facilitate employee and non-employee healthcare workers in
reporting and directly addressing patient and environmental safety concerns.
Ensure that the department environment is free from recognized hazards that
create a risk of injury to healthcare workers, patients, and/or visitors.
reporting and directly addressing patient and environmental safety concerns

Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.