Director, Quality & Risk Management

Description

We are recruiting for a Director, Quality and Risk to join our Behavioral Health Team.

Job Summary:

Directs and coordinates functions and activities of nursing within the division and assigned clinical operation departments. Consults with and advises SVP, COO and DVP, and CCO of Clinical Operations on the general operation of the division’s programs, units and hospitals. Collaborates on strategic planning, financial management, quality integration of patient services practices. Develops divisional nursing goals, objectives, standards of performance, policies and procedures. Organizes divisional nursing department and hospital departments according to administrative and nursing service guidelines; ensures compliance with legal, organizational, and medical staff standards. Has authority and responsibility for establishing, directing, and implementing the Standards of Nursing Practice and the nursing operations and financial matters related to all nursing care areas and functions.

Essential Functions:

• Participates in the advancement of Kindred Behavioral Health’s clinical and business objectives.
• Formulates and implements strategic plans related to strengthening core clinical and business goals, including improving patient experience, improving patient outcomes, reducing negative outcomes, streamlining admission processes, and developing programs and processes that allow the company to serve patients as populations and community needs evolve.
• Manages multiple divisional departments and managers who supervise staff members in multiple facility locations that may include, but is not limited to: Nursing, Quality and Risk Management, and Clinical collaboration.
• Ability to direct the preparation of short term and long range plans and budgets based on broad corporate goals and growth objectives.
• Maintains a sound plan of corporate organization establishing policies to insure adequate management development and to provide for capable management succession. Develops and installs procedures and controls to promote communication and adequate information flow. Establishes operating policies consistent with the Division’s broad policies and objectives and ensures their execution.
• Evaluates the results of overall operations regularly and systematically and reports these results to the Divisional Leadership Team, Hospital Chief Executive Officers.
• Ensures that the responsibilities, authorities, and accountability of all direct subordinates are defined and understood. Responsible for the overall direction, coordination and evaluation of the subordinate units/departments. Maintains an environment of collaboration and cooperation among hospitals, units and locations of management services agreements.
• Ability to effectively present written and verbal information to executive leadership, medical staff, public groups and Governing Body. Ability to read, analyze and interpret financial reports and contracts.
• May assume the administrative responsibilities of a hospital CEO in his/her absence.
• Promotes staff development by establishing a professional environment that supports accountability and autonomy. Shares knowledge and skills with nursing staff, students, colleagues, and others and acts as a role model and mentor.
• Leads nurse recruitment and retention efforts by planning and implementing new and creative initiatives to both attract and retain nurses and other key employees. Supports the interview and selection process for new nursing staff. Provides leadership in human resource development and management. Provides guidance and counsel to nursing leadership and staff. Provides adequate communication mechanisms within all departments and disciplines.
• Maintains confidentiality of employee information to assure employee rights are protected.
• Adheres to and promotes Equal Employment Opportunities and the facility's Affirmative Action Plan. Demonstrates ability to fairly and consistently apply the disciplinary process.
• Reviews and analyzes documents such as policies and procedures, meeting minutes, committee reports, governing board meeting minutes, quality council meeting minutes, etc., to assess compliance to TJC standards, Kindred policies and other regulatory or licensing agency requirements.
• Provides consultative services (which may include a focus visit) and serves as an expert resource for division, region and facility leadership in the areas of nursing practice.
• Assists with the development of core, standardized nursing clinical programs and systems to assist facilities to meet regulatory requirements and provide quality care.
• Performs and directs facility-level clinical analysis through on-site visits and report reviews.

Knowledge/Skills/Abilities/Expectations:

• Expert working knowledge of The Joint Commission (TJC) accreditation for Behavioral Health.
• Hospital standards Center for Medicare Medicaid Services (CMS) regulations.
• Ability to lead a facility team’s nursing department through regulatory and accrediting body survey activity, including developing any plan of correction and implementing systems of surveillance that ensure ongoing compliance and survey readiness.
• Ability to evaluate risk incidents and complete Plans of Correction.
• Ability to develop forms, tools and resources to ensure compliance with THC and CMS regulatory guidance.
• Excellent oral and written communication and interpersonal skills.
• Basic computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet software.
• Ability to demonstrate critical thinking, appropriate prioritization and time management skills.
• Ability to work under stress and to respond quickly in emergency situations.
• Ability to spend a limited amount of time on travel required.
• Must have good and regular attendance.
• Approximate percent of time required to travel: Intermittent and at times extensive.
• Performs other related duties as assigned.

Qualifications:

• Master’s Degree in Nursing.
• Master’s Degree in Health Administration or Business Administration preferred.
• Registered Nurse in a minimum of one state.
• Minimum of five years’ experience in healthcare administration/management with a minimum of two years’ experience at a senior nursing management level. Minimum of five years’ experience in hospital management in an inpatient psychiatric environment. Graduate level education may substitute on a year-to-year basis for the required experience.

Depending on candidate’s qualifications, this position may be filled at a different level.