EXPERIENCE 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 soft ware. Preferred: Recent hospital leadership; quality and risk management exposure in a managerial role. EDUCATION 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.

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