DIRECTOR OF QUALITY

Reports To: Chief People Officer

Employee Type: X EXEMPT NON-EXEMPT

POSITION SUMMARY:

The Director of Quality, Risk, and Compliance is responsible for ensuring the successful day-to-day operations of the Quality, Risk, and Compliance Departments. The Director will be primarily responsible for overseeing the operational efficiency and quality of services within the Quality Department, including direct supervision of support staff. They will make efforts to improve quality outcomes and operations in a way that contributes to enhanced experience for both staff and patients. The Director will also oversee the functioning of key systems vital to departmental operations and lead and facilitate process improvements in patient access measures, department workflow, population based quality improvement, and patient experience. This leadership role also encompasses leading the hospital’s initiatives to maintain the highest standards of patient safety, clinical quality, and regulatory compliance. The Director will oversee risk management strategies, ensure adherence to legal and accreditation requirements, manage contract processes, and address patient complaints. The ideal candidate will foster a culture of continuous improvement, accountability, and transparency across all hospital operations.

This job description is intended to identify some of the primary duties and responsibilities. MAYERS MEMORIAL HOSPITAL DISTRICT reserves the right to modify, supplement, delete or augment the duties and responsibilities specified in this position description, at MAYERS MEMORIAL HOSPITAL DISTRICT’S sole and absolute discretion.

POSITION QUALIFICATIONS:

Bachelor’s degree in Healthcare Administration or related field required, Master’s Degree in Healthcare Administration or related field preferred.
Ability to plan and execute large scale administrative programs including preparing budgets, establish and maintain cooperative relationships with the general public, and other professional groups, with other public agencies and departments of government, communicate effectively in oral and written form.
Must possess the ability to make independent decisions when necessary and demonstrate aptitude under stressful situations.
Skilled in examining current practices/policies and recommending proven improvements.
Strong knowledge of healthcare regulations, accreditation standards, and legal issues.
Minimum of 5 years of experience in healthcare quality, risk management, or compliance.
Experience with hospital informatics and data analytics.
Certification such as Certified Professional in Healthcare Quality (CPHQ) or Risk Management Certification is preferred.
Management experience required.

POSITION RESPONSIBILITIES:

General Competencies:

Professional behavior is demonstrated, both when on duty and as a representative of MMHD outside of normal work hours.
Ability to work with others, at all levels within the organization, and collaborate effectively.
Above-average interpersonal, problem-solving, and written and oral communication skills.
A positive working relationship with patients, visitors, and facility staff is demonstrated.
Organizational ability and time management are demonstrated.
Produces deliverable products on time, within budget with minimal direction.
Demonstrates the ability to compile and organize data using Microsoft Office Applications. Ability to make appropriate recommendations or conclusions, given the data obtained.
Maintains an organized set of records, upon request, for the functions that are performed within the scope of this job.
Communicates appropriately and clearly to directors, managers, and coworkers.
Performs all assigned tasks accurately, to include proper spelling and grammar, reference materials, and minimal mathematical calculation.
Takes direction from others to include those employees of other departments with which he/she works on a temporary basis in accordance with the chain of command.
Maintains all information as confidential as appropriate, to include payroll, personnel information, and other information obtained during the course of performing job duties that is confidential.
Demonstrates ability to effectively use office machines in the performance of job functions.
Answers phone calls, assists public, and forwards appropriately if necessary and in a professional and friendly manner.
Other duties as assigned.

Specific Competencies:

Quality Improvement & Patient Safety:

Develop, implement, and monitor hospital-wide quality improvement initiatives.
Lead efforts to enhance patient safety and clinical outcomes.
Analyze data from EHRs and other informatics systems to identify trends and areas for improvement.
Ensure the continuous Quality Improvement process is accomplished on an ongoing basis.
Implement, develop and run reports to improve transparency across departments.

Risk Management:

Identify, assess, and mitigate risks related to patient care, staff, and hospital operations.
Oversee investigation and resolution of adverse events, patient complaints, and malpractice claims.
Review and monitor Risk Event Reports and Concerns/Complaints, directing appropriate actions and reporting pertinent information to the Executive Leadership team.
Develop and implement risk management strategies in coordination with hospital leadership.

Regulatory Compliance & Accreditation:

Ensure hospital adherence to all federal, state, and local regulations, including CMS, ACHC, Compliance Team and other standards.
Develop policies, procedures, and protocols aligned with regulatory requirements.
Coordinate information for regulatory agency reviews and participate in all facility surveys, including plans of correction.
Develop, report, and implement a plan of correction (POC) when necessary.
Develop relationships with CDPH, ACHC, and other accreditation and regulatory agencies to ensure smooth communication.

Contract Management:

Oversee the review and management of hospital contracts with vendors, payers, and partners.
Ensure contractual obligations are met and risks are minimized.
Develop and maintain a comprehensive contract management system to ensure all contractual obligations are met, deadlines are tracked, and compliance is maintained, thereby preventing automatic renewals without proper review and approval. This system will also facilitate timely renegotiation or termination of contracts as needed.

Informatics & Data Management:

Supervise hospital informatics personnel.
Leverage data analytics to inform decision-making and performance improvement.
Coordinate and oversee process and workflow enhancements within the Electronic Health Record (EHR) systems to optimize efficiency, ensure seamless clinical operations, enhance patient satisfaction, and improve charge capture accuracy.

Patient Complaints and Malpractice Management:

Oversee the process for managing and responding to patient complaints.
Manage malpractice claims, coordinate legal responses, and work with legal counsel and insurance broker as needed.

Financial & Administrative Oversight:

Help plan, develop, implement, and manage the annual budget for the Quality Department.
Review financial reports as required.
Review and monitor work schedules, duties, and productivity of Quality Department personnel; effect changes as needed.
Conduct annual reviews and approve timecards for Quality Department personnel.

Operational & Strategic Planning:

Develop short- and long-term goals in collaboration with hospital administration, aligning with the Districts Strategic Plan.
Participate in facility projects, public relations, and strategic planning processes.
Contribute to the development of the hospital’s strategic goals and overall management.

Clinical & Departmental Oversight:

Collaborate with the Provider Relations Coordinator and Medical Staff regarding quality and patient/resident care.
Conduct regular department and patient rounds, keeping informed about patient/resident census and acuity.
Analyze and evaluate department services to ensure quality care and appropriate productivity.

Policy & Disciplinary Actions:

Investigate irregularities and policy violations, taking corrective actions per facility policy.
Follow disciplinary procedures, document actions, and report to administration as needed.

Facilities & Safety:

Participate in all State and Federal surveys, including acute hospital, skilled nursing, fire/life safety surveys.
Develop, report, and implement plans of correction (POC) for survey deficiencies.
Contribute to safety and emergency preparedness initiatives.

Board Reporting & Executive Engagement:

Report on quality, risk, and compliance metrics to the hospital’s Board Quality Committee on a monthly basis.
Engage with executive leadership to communicate performance, challenges, and improvement initiatives.

Team & Community Engagement:

Actively participate in hospital meetings and serve as a consultant to other departments regarding quality, risk, compliance, informatics, and contract management.
Engage in public relations and community outreach as appropriate.

Professional Requirements:

Adheres to dress code; appearance is neat and professional.
Completes annual education requirements if applicable.
Maintains regulatory requirements.
Wears identification while on duty.
Attends annual evaluation and participates actively in this process.
Reports to work on time and as scheduled; completes work in designated time.
Attends all meetings as appropriate.
Exhibits the mission, ethics and goals of Mayers Memorial Hospital District in the performance of job duties.

WORKING CONDITIONS:

Willingness to work beyond normal working hours and in other positions temporarily when necessary.
Is involved with personnel, visitors and government agencies, etc., when necessary.
Must function independently, have personal integrity, have flexibility and the ability to work effectively with other personnel, clients and support agencies.

PHYSICAL REQUIREMENTS: