The Director, Quality, Safety and Risk Management manages and coordinates the hospital’s quality improvement, quality assurance and risk management initiatives. The Director works to organize and align measures associated with regulatory and accreditation programs. The Director assists in the implementation of the Quality Plan by collecting, managing and reporting data to leadership teams and team members. Serves as the organizational lead for performance improvement, quality and The Joint Commission initiatives and acts as Risk Manager. Assists Environmental/Life Safety Officer to perform system wide education and inspections. Responsible for the performance, including fiscal viability for all functions of the Quality Management department.
Manages and/or leads materials management team members.
Explores opportunities to improve business practices and performance across the institute through the use of guidance, development, mentorship and modeling optimal stewardship.
Develops and implements departmental and interdepartmental performance improvement activities.
Participates in leadership activities across the hospital and within materials management.
Fosters an environment of optimal stewardship and models as such by using a consultative approach throughout the department
Manages department budget monitoring progress of departmental and program goals and makes corrective action plans when appropriate
Monitors and reports budgetary goals established during budget approval process to include operational and service delivery goals.
Participates in preparation of budget projections providing adequate detail to support budget projections.
Takes effective actions to address variances promptly and deals promptly and effectively with the variances.
Ensures core team member levels are appropriate through the recruitment and hiring of qualified team members to deliver an efficient and effective level of patient care/customer service through continual assessment. Determines and addresses daily team member needs, schedules, and coverage within department and establishes cost efficient contingency plans. Including ongoing awareness of productivity targets and performance using agreed upon guidelines.
Ensures all team members are oriented to the transdisciplinary culture and expectations on the unit. Cleary communicates the structure, practice, and expectations of the Sheltering Arms Institute care model.
Provides support and coaching to team members to help them transition into and maintain a philosophy of transdisciplinary teamwork through role release and maintaining the highest standards of patient satisfaction.
Models transdisciplinary behavior and leadership, assists in setting unit expectations regarding behavior, assists families and patients with their needs to foster a more collaborative, meaningful, and engaged patient care experience.
Facilitates access to and engagement with formal and informal interprofessional education for all team members, including learners.
Assumes overall responsibility for service, activities and outcomes in area of responsibility.
Addresses patient/visitor complaints/concerns timely and appropriately. Proactively ensures that supervisor is notified of potential situations. Adjusts communication timeliness according to urgency.
Ensures that all equipment in area of responsibility complies with standards to ensure safety and that maintenance is performed timely and appropriately. Ensures no expired pieces of equipment or supplies are utilized. Takes initiative to investigate and make recommendations for department equipment needs.
Develops business goals and objectives in area of responsibility that are consistent with the Sheltering Arms Institute strategic plan/goals.
Researches information and actively participates in the coordination and development of new service(s) to enhance the Sheltering Arms Continuum of Care or services that enhance the efficiency of Sheltering Arms processes including Contract Services. Leads strategic planning and program initiatives for his/her area and performs specific projects/studies relating to the operation & growth of specific departmental functions/services. Ensures effective communication to team members and those involved.
Actively involved in marketing departmental/program services to potential customers as appropriate.
Develops and maintains a thorough understanding of own services, as well as an understanding of all service lines and continuum of care thorough out the community, and is able to respond to inquiries with adequate depth and detail.
Actively supports organizational customer service initiative.
Develops and implements department/program monitors to evaluate performance and identify improvement solutions. A systematic process for performance improvement within area of responsibility is established and implemented.
Uses customer service survey data to gather information on departmental performance; evaluates the data, reviews trends and takes appropriate action.
Ensures that all department/program activities fall within Corporate Compliance guidelines.
Actively participates in meetings through appropriate presentations, comments, discussions, etc.
Participates in or supports education at local, national or international conferences and symposia related to areas of responsibility.
Relentlessly pursues maximum recovery for each patient through leadership of team members and process improvement.
Integrates program services with other community organizations to create a system of care for maximum benefit to individuals and the community as a whole.
Quality, Safety and Risk Management
Oversees the hospitals quality management program; including patient safety, quality of care, patient relations and satisfaction, regulatory compliance (accrediting bodies such as TJC, CMS, OSHA, State, etc.), and survey readiness to include tracer survey activities, risk management and safety, performance improvement, and infection control.
Develops strategic plans and policies for improved quality throughout the hospital.
Actively participates in the Quality program and utilizes data/information to further enhance the quality of patient care offered at Sheltering Arms.
Functions as a team leader and collaboratively for selected projects, including selecting team members, conducting team meetings, developing process reports and presenting materials and recommendations for review and comment.
Assists with development and implementation of department based and transdisciplinary performance improvement activities.
Assists departments/individuals in converting to statistical methodologies for analyzing data.
Investigates quality of care issues including participating and leading front line staff in root cause analysis, learning from defects, failure mode and effects analysis, the 5 whys and other quality tools as required with sensitivity and confidentiality.
Represents Sheltering Arms Institute in the Commonwealth Emergency Preparedness functions.
Ensures notification to legal consultants of all actual and potential claims and acts as a liaison with consultants and SAI for investigations and necessary preparations as needed.
Implements, maintains, tracks and trends facility wide occurrences and reporting of those occurrences.
Compliance and Education
Stays current on regulatory changes that affect operations.
Actively pursues information on professional issues that affect the department and/or operations and communicates this information to director and/or other managers.
Identifies changes/improvements to operations in response to professional issues/changes in practice. In consultation with supervisor, takes actions to alter operations to comply with the new regulations. Conducts follow-up to ensure that the revised processes have been correctly implemented.
Develops, updates, and implements training materials and procedures that enable team members to remain up-to-date on changing regulations that affect the operations.
Revision of and/or development of departmental/discipline specific/operational policies and procedures on an ongoing basis.
Consistently interprets and applies hospital, administrative, and Human Resources policies and procedures in all pertinent situations.
Maintains survey readiness and achieves positive results in all reviews done by accrediting and regulatory agencies in area of responsibility.
Actively consumes information regarding overall healthcare trends and rehabilitation specific policy.
Performs other duties as assigned.
Qualifications and Skills
3 years of management experience in health care required.
Demonstrated work history in quality, safety and risk management required.
Experience in management and development of team members.
Strong leadership and interpersonal skills, organizational and communication skills.
Education and Certifications
Bachelor’s degree in health-related sciences or clinical science. MSN, MBA or MHA preferred.
CPHQ or CPPS; if not upon hire willingness to obtain such certifications within 6-12 months of hire.
RN, CRRN, and/or CJCP preferred.
Internal Number: 5785
About Sheltering Arms Institute
Sheltering Arms Institute, a collaboration with VCU Health is scheduled to open its doors in late spring 2020. Sheltering Arms Institute combines inpatient beds from Sheltering Arms Hospital and VCU Health to create a multi-million dollar state-of-the-art destination hospital and is a leader in rehabilitation medicine throughout the mid-Atlantic region. The organizational values and transdisciplinary approach to care catalyze improvements in patient outcomes and the realization of Sheltering Arms Institute’s vision to reinvent rehabilitation. SAI leaders and team members align behaviors with this approach to build team cohesion and to foster a culture that team members, patients, families and community members experience during their interactions with the Institute.