Campus Pride Jobs

Position Summary:

The Director of Quality and Risk reports to the Chief Medical Officer and is responsible for

compliance, quality, risk management and policy development in accordance with Mid-Valley

Hospital and Clinic policies. The Quality Director will reflect the mission, vision and value

statements of MVH and Clinic in both the hospital and clinic and the communities that we serve.

Position Competencies

• Project Management and Planning
• Patient Privacy
• Ethical Conduct
• Flexible Leadership Style
• Critical Thinking / Decision Making
• Communications Proficiency
• Performance Management
• Personal Effectiveness/Credibility and Trust
• Complex Problem Solving/Analysis
• Strategic Thinking and Mindset
• Technical Capacity
• Desktop IT and EHR System

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``` - Hospital and Clinic licensure, certification, and accreditation - District-wide management systems and reporting; - All facilities planning and construction, including various bidding and statutory requirements relating to construction, maintenance, architects, and engineers

Essential Job Functions

• Develop, implement and oversee quality improvement to ensure delivery of the highest

quality patient care, optimal patient flow, provider productivity and continuity of care.

• Develop a conceptual framework for quality measurement and improvement activities

across clinic sites. Summarize findings in the annual Quality Improvement (QI) Plan.

• Work with CEO, COO, CFO, CMO, as well as members of Management to develop and ensure the implementation of policies to minimize risk within the organization.
• Manage and oversee the Infection Control/EE Health Nurse and Education Coordinator.
• Coordinate with the Cerner and EMR Super User to develop audit systems,

perform data analysis and prepare reports related to measuring objectives and tracking

outcomes as required by grants, contracts or MVH need. Analyze and report data, as

required, in conjunction with the QI Reporting calendar and for continued recognition

through NHSN, DOH and ACO activities.

• Participate in quality components of DNV, DOH, CDC and Accountable Care Organization
• Work with the CMO to develop new or update existing clinical outcome measures, protocols, policies and procedures to ensure compliance with policies through a peer review process.
• Engages in the planning and implementation of the Corporate Compliance Program,

including risk management reduction, which includes ensuring compliance with MVH policies and procedures as well as health, safety and regulatory requirements including HIPAA, OSHA, and DNV.

Investigate and act, in conjunction with COO, on matters related to compliance, including coordinate internal investigations and any resulting corrective action with all departments, contracted vendors, etc.

Develop and review policies and programs that encourage managers and employees to report suspected fraud or other improprieties.

Participate in long-range planning including the evaluation of patient satisfaction, current services and programs to increase, and market services to the community and to position MVH for change and growth.

Ensure that the responsibilities, authorities, and accountability of all direct subordinates are defined and understood.

Accesses Private Health Information (PHI) as needed to provide and promote high quality health care and to protect the public's health and well-being.

Ensures compliance with all State and Federal Regulations.

Directs and supports performance improvement activities for the hospital.

Supports and maintains a culture of safety an