JOB SUMMARY:

The Director of Risk Management & Quality, RN is responsible for overall hospital quality/performance improvement and monitoring of the organization. The Director of Risk Management & Quality, RN ensures the provision of differentiated quality and safety, patient-focused, outcomes based, and cost-effective medicine in the hospital setting. Provides oversight of the hospital�s grievance and compliant process.

DUTIES AND RESPONSIBILITIES:

Essential Job Duties

• Responsible for implementing and overseeing all aspects of the quality improvement and coordinating patient safety data reporting, analysis and clinical outcomes at the facility levels that align with the regional direction for quality.
• Responsible for an integrated approach to quality and patient safety and occurrence reporting, analysis and clinical outcomes with the facility that includes all facets of quality such as Regulatory, Performance Improvement, and Core Measures.
• Has the authority and responsibility to develop, implement and manage the Accreditation/Regulatory Compliance Program for the hospital.
• Contributes to the hospital management team by promoting regulatory compliance and safety in conjunction with providing leadership, and assuring safe patient care.
• Responsible for coordinating activities in: 1) Clinical excellence and patient safety; 2) process improvement and outcomes management; and 3) regulatory readiness.
• Serves as a resource related to clinical quality, patient safety, regulatory and quality improvement issues, and activities related to accreditation.
• Completes established competencies for the position within designated introductory period.
• Initiates, coordinates, and manages all investigational and evaluation activities associated with professional and general liability occurrences and claim pre-litigation files.
• Negotiates resolution with authority from BSW-Sunnyvale and Corporate Risk Management team.
• Provides basic and complex preventative risk management assessment of processes, procedures, and programs, including in-service education, consultation, liaison activities, and on-call emergency assistance to providers.
• Completes established competencies for the position within designated introductory period.
• Other related duties as assigned.

PROFESSIONAL REQUIREMENTS:

• Adheres to dress code, appearance is neat and clean.
• Completes annual education requirements.
• Maintains regulatory requirements, including all state, federal and JCAHO regulations.
• Maintains and ensures patient confidentiality at all times.
• Reports to work on time and as scheduled.
• Wears identification while on duty.
• Attends annual review and performs departmental in-services.
• Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
• Represents the organization in a positive and professional manner.
• Attends committee, CQI and management meetings, as appropriate.
• Resolves personnel concerns at the departmental level, utilizing the grievance process as required.
• Ensures compliance with policies and procedures regarding department operations, fire, and safety and infection control.
• Effectively and consistently communicates administrative directive to personnel and encourages interactive departmental meetings and discussions.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department.

REGULATORY REQUIREMENTS:

• Experience: Must have a minimum of 10 years clinical experience as an RN.
• 2-5 years experience in Quality/Risk Management Required
• Education: Must have BSN and be currently licensed as a Registered Nurse in the State of Texas.
• Preferred Education: Masters degree in a healthcare related field.

Language Skills:

• Able to communicate effectively in English, both verbally and in writing.
• Additional languages preferred.

Skills:

• Basic computer knowledge.

Physical Demands:

• For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.