Director-Quality RN

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