Director of Quality and Risk
Company: chinesehospital-sf.org
Location: San Francisco
Posted on: October 19, 2024
Job Description:
Search Hit enter to search or ESC to close About This Role
Department Quality and Risk Reports to VP Quality, Risk, Compliance
Medical Staff Type Full Time Requisition # 12570 Position
SummaryThe Director of Quality and Risk provides leadership,
management and administrative oversite of the development and
implementation of the hospitals quality, patient which includes
internal, external, licensing departments and risk management. The
Director will develop metrics in quality and patient safety, ensure
all policies and procedures are in compliance and act as an expert
resource for all hospital departments.Essential Duties and
Responsibilities
- Ensure the organization maintains appropriate IT Security,
administrative, technical, and physical safeguards to protect
health information and work in collaboration with the Chief
Information Security Officer or designee.
- Engage leadership team, employees, and volunteers in a Culture
of Safety.
- Work with management in the development and implementation of
appropriate internal controls and measurements to reasonably ensure
that the activities of the organization comply with the law,
regulation, and rules.
- Evaluate the organization for potential risks, opportunities
for improvement, and propose solutions for minimizing and
mitigating the risks.
- Manage the incident reporting process (e.g. grievances, adverse
events, and violations) and develop a records management system for
the risk management program that is secure, accurate, complete, and
evaluated regularly for destruction or retention.
- Promptly inform the Administrator and Chief Nursing Operations
Officer (CNO) and appropriate department heads regarding any
identified organizational risk and discuss recommendations for
mitigating the risk.
- Prepare dashboard and analysis of reported incidents with
solutions/proposed solutions.
- Investigate and respond to patients/residents/representatives
with grievances and concerns
- In conjunction with the CNO and Administrator, performs complex
Root Cause Analysis (RCA) investigations and consults with legal
counsel, the Board, the VP of Operations, and/or the Chief
Executive Officer, to determine the appropriate response of the
organization to detected violations and opportunities for
improvement.
- Develop, implement, communicate and maintain a quality plan to
ensure the Hospital is in compliance with regulatory
requirements.
- Develop internal measures such as peer review to ensure the
safety and quality of care provided by the Hospital to
patients.
- Lead site effort to implement and train leadership,
departmental managers, and staff to ensure site is compliant with
all state and federal regulations.
- Plans and conducts internal monitoring to ensure the
organization is compliance with regulatory requirements.
- Observe and evaluate processes to make appropriate decisions on
issues relating to quality program adherence and improvement.
- Coordinate and manage the activities and investigations of
patient care
- Develops, initiates, maintains, and revises policies and
procedures for the general operation of the Compliance Program and
its related activities to prevent illegal, unethical, or improper
conduct.
- Manages day-to-day operation of the Program.
- Works with CHA General Counsel to periodically review and
updates Standards of Conduct to ensure continuing currency and
relevance in providing guidance to management and employees.
- Collaborates with other departments to direct compliance issues
to appropriate existing channels for investigation and resolution.
Consults with CHA General Counsel as needed to resolve difficult
legal compliance issues.
- Responds to alleged violations of rules, regulations, policies,
procedures, and Standards of Conduct by evaluating or recommending
the initiation of investigative procedures.
- Develops and oversees a system for uniform handling of such
violations.
- Acts as an independent review and evaluation body to ensure
that compliance issues/concerns within the organization are being
appropriately evaluated, investigated and resolved.
- Monitors, and as necessary, coordinates compliance activities
of other departments to remain abreast of the status of all
compliance activities and to identify trends.
- Identifies potential areas of compliance vulnerability and
risk; develops/implements corrective action plans for resolution of
problematic issues, and provides general guidance on how to avoid
or deal with similar situations in the future.
- Provides reports on a regular basis, and as directed or
requested, to keep the Corporate Compliance Committee of the Board
and senior management informed of the operation and progress of
compliance efforts.
- Ensures proper reporting of violations or potential violations
to duly authorized enforcement agencies as appropriate and/or
required.
- Establishes and provides direction and management of the
compliance Hotline.
- Institutes and maintains an effective compliance communication
program for the organization, including promoting (a) use of the
Compliance Hotline; (b) heightened awareness of Standards of
Conduct, and (c) understanding of new and existing compliance
issues and related policies and procedures.
- Works with the Human Resources Department and others as
appropriate to develop an effective compliance training program,
including appropriate introductory training for new employees as
well as ongoing training for all employees and managers.
- Monitors the performance of the Compliance Program and relates
activities on a continuing basis, taking appropriate steps to
improve its effectiveness.
- Follows Hospital and Department policies and procedures at all
times, including but not limited to: Administrative Manual,
Environment of Care, Human Resources, Infection Control, Corporate
Compliance, Code of Ethics, etc.
- Customer Service - Provides excellent customer service and
shows compassion to all patients, visitors and co-workers. Seeks
feedback to ensure all needs are met. Anticipates and recognizes
the concerns of others, even if those concerns are not openly
expressed.
- Accepts and performs other duties as assigned.Qualifications
- CA Licensed Registered Nurse is required
- Three to five years of experience in ongoing monitoring
techniques in quality management and regulatory surveys
- Knowledgeable with TJC/DHS/CMS regulatory standards as well as
TJC disease- specific care certification process
- Demonstrated experience working with physicians, physician
leaders, and Administrative leadership
- Well-developed organizational, communication and analytical
skills.
- The ability to critically evaluate and troubleshoot patient
care concerns is essential.
- Experience in LEAN and six sigma preferred.
- Excellent computer skills, exposure to managing people and
projects, and the ability to handle multiple tasks.
- Certification in Healthcare Privacy and Corporate Compliance
(CHPC) preferred in ideal candidates. Education: A Bachelor's
degree required; Master's Degree in health care administration,
nursing, business and JD preferred. Course in medical staff office
functions.
- Experience: A minimum of 10 years' experience in a hospital or
healthcare organization, to include demonstrated leadership.
Familiarity with hospital or healthcare operational, financial,
quality assurance, and compliance regulations required. Clinical
nursing and hospital experience preferred.
- Organizational, managerial, problem-solving skills;
communication skills; ability to work independently and to assume
responsibility;
- Knowledge of current accreditation standards, state and legal
requirements pertaining to the medical staff
- Computer proficiency (Microsoft Office) (EMR knowledge a
plus)
- Ability to effectively present information, both verbal and
written.Physical RequirementsWhile performing the duties of this
job, staff is regularly required to sit, stand, walk, talk, and/or
listen. He/she uses his/her hands to do computer work, write
reports, do equipment set-up/cleaning/storage, clerical support,
etc. He/she will be using the phone frequently. Good vision is
needed to be able to read schedules, enter accurate data, etc.
He/she must have good general health and demonstrate emotional
stability so as to carry out the above-enumerated duties.
- Able to lift up to 30 pounds.
- Stand, walk, and move 50% of the day.
- Use proper body mechanics when handling equipment.Compliance
RequirementsComplies with Chinese Hospital Compliance Handbook
including Code of Ethics and all statutes, regulations, guidelines
applicable to federal and state programs. Responsibilities include,
following the guidelines and reporting suspected violations of any
statute, regulations, agreements or guidelines applicable to all
healthcare programs.Base Pay ScaleStarting at $156,125-$203,715 per
year. The salary of the finalist selected for this role will be set
based on a variety of factors, including but not limited to,
internal equity, experience, education, specialty and training.
This pay scale is not a promise of a particular wage.
#J-18808-Ljbffr
Keywords: chinesehospital-sf.org, Mountain View , Director of Quality and Risk, Executive , San Francisco, California
Didn't find what you're looking for? Search again!
Loading more jobs...