Required : Leadership, communication, and interpersonal skills and thorough understanding of quality management theory and process. Minimum 5 years clinical experience. Comfortable and skilled at working with stakeholders in the organization. Knowledge of PC based computer software.
Preferred: Recent hospital leadership; quality and/or risk management exposure through clinical activity, consultative activities, or a managerial role.
Required: BSN with current Virginia State Licensure.
Preferred: Masters degree.
SPECIFIC ELEMENTS AND ESSENTIAL FUNCTIONS*:
1. Responsible for the administrative and operational oversight of all hospital (enterprise) performance improvement, quality outcomes, risk reduction/mitigation, infection control, peer review, patient safety, and regulatory management operations. *
2. In collaboration with the Quality Management Committee, Executive Officers, Medical Executive Committee, and Board of Trustees, responsible for the development of the hospital’s quality and risk management strategy and annual goals. *
3. Leads the Quality and Risk Management Department in the development and application of quality management and risk reduction strategies throughout the hospital. *
4. Assumes responsibility for communication and education regarding quality and risk management activities in the organization, as well as the medical community and governing body, and serves as a resource. *
5. Responsible for and provides direction to the QRM Department, as well as QM Committee, Peer Review, Infection Control, Outcomes Council, JCAHO Readiness, and Patient Safety Committees. *
6. Leads the QM Department within defined financial parameters. *
7. Plans, coordinates and monitors comprehensive Medical Staff QI programs as indicated. *
8. Plans, coordinates and monitors comprehensive hospital QI program; serves as the Chief Clinical Performance Officer representing the facility at the Division and Corporate level. *
9. Plans, coordinates and monitors hospital quality incentive programs. *
10. Serves as an organizational resource for QA/QI, performance improvement, and risk reduction information. *
11. Interacts with Executive, Administrative, and Medical Leaders to gain support for QI activities. *
12. Coordinates and directs activities related to the JCAHO accreditation and continuous readiness, and in collaboration with hospital leadership, ensures that JCAHO deficiencies are addressed and resolved. *
13. Oversees the Risk Management Program and serves as a Hospital Risk Manager and the Patient Safety Officer. *
14. Works collaboratively with HCI, legal counsel, and Executive Administration in coordinating and overseeing Risk Management activities. *
15. Develops, coordinates, and maintains facility occurrence reporting system. *
16. Works to expand knowledge of quality bringing new ideas and concepts to LGMC