About

• Description
• Spanish Peaks Regional Health Center is seeking a dedicated and mission driven Director of Quality, Risk & Patient Experience to lead our organization’s efforts in building a strong culture of safety, delivering high quality patient care, and maintaining excellence in regulatory compliance. This leadership role reports to the Executive Director of Operations and oversees all facets of quality, risk management, and patient experience across the facility.

• The Director of Quality, Risk & Patient Experience is responsible for the professional management of SPRHC’s comprehensive regulatory, quality, and risk programs including patient relations. This leader will drive continuous improvement, measure and elevate care quality, and ensure compliance with state and federal regulations. In partnership with clinical and administrative teams, the Director advances our mission, vision, and values by championing safe, equitable, and patient-centered care.
• Requirements

Essential Job Functions

• • Develop, implement, revise, oversee, and enforce the facility’s quality program.
• • Maintain a comprehensive, effective system for monitoring and evaluating the quality of patient care and services provided in a cost-effective manner in a continuum of improving organization performance.
• • Develops and maintains facility policies and procedures for quality assurance and performance improvement.
• • Processes quarterly updates to provide status reports to the Board of Directors on quality assurance programs.
• • Establish continuous improvement in patient care performance, minimizing liability and promoting appropriate utilization of patient care resources.
• • Ensures the consideration of the role of cultural, social and behavioral factors in the accessibility, availability, acceptability and delivery of information and services.
• • Responsible for participation review, and documentation of various departmental audits.
• • Provides technical leadership to others through project management or ongoing consulting.
• • Oversees and ensures that consistent action be taken for failure to comply with quality improvement policies and procedures for all employees on the workforce and for business associates.
• • Promotes the mission, vision, and values of SPRHC.
• • Serves as collaborator and team member in maintaining, updating, and implementing the Quality Improvement Plan for SPRHC.
• • Develops and maintains policies and procedures for loss prevention and risk control.
• • Assists SPRHC departments with the coordination of audit information, data-gathering mechanisms and assisting with developing controls and contingency plans.
• • Leads the identification, communication, measurement, and management of SPRHC-related risk; prepares action plans to decrease risk factors.
• • Assists, as necessary, with the accumulation, display, routing, and dissemination of the information related to risk to appropriate sources (committees, physicians, departments).
• • Develops, maintains, and communicates unusual occurrence procedure. Ensures that procedure provides measures for reporting, monitoring and action plans for the reduction of risk.
• • Obtains and utilizes knowledge of applicable federal and state laws, regulation, and accreditation standards to identify regulatory risk and maintain compliance.
• • Attends and actively participates in all QAPI and risk-related training and meeting activities.
• • Serves as a liaison between patients, visitors, volunteers, and the healthcare team focused on enhancing the understanding of hospital policies and services.
• • Responds to patient/visitor complaints and inquiries, independently working to resolve and/or initiate resolution of issues.
• • Proactively participates with departments to improve patient satisfaction.
• • Gathers and analyzes qualitative statistics to identify trends in patient satisfaction, assisting to communicate these trends to the organization for performance improvement and quality of care issues.
• • Educates SPRHC staff members, leaders, and providers in the use of service recovery tools and behaviors.

• Minimum Required Education/Experience: Bachelor’s degree in nursing, healthcare administration, or related field. Experience in healthcare quality and risk management. Minimum of three years healthcare work experience. Computer applications work experience is preferred.

Pre-Employment Knowledge, Abilities and Skills

• • Ability to operate general office equipment including computer software applications (e-mail, surveillance equipment/cameras).
• • Ability to organize data including collection methodologies, analysis and presentation.
• • Demonstrated ability to recognize and respond to opportunities for improvement through continual learning, changes in approach based on situation and professional practice behavior.
• • Knowledge of hospital quality practices, foundation of health law and CMS (Centers for Medicaid and Medicare Services) conditions of participation.
• • Outstanding verbal and written communication skills.
• • Ability to establish and maintain effective relationships with the public, other agencies, employees and administration.