
Description
General Summary of Position
The Director of Quality, Safety, Accreditation, Risk and HIM is responsible for planning, organizing and managing the coordination of the organization's performance improvement activities, required measurement and monitoring. The Director is responsible for the planning and coordination of the tri-annual Joint Commission and all other regulatory body surveys. The Director's responsibilities also include facilitating cross functional teams and the development and maintenance of a project management infrastructure to support business development. The Director will plan, organize, analyze and manage the reporting of outcomes for MedStar Southern Maryland Hospital Center and MedStar Health. This position functions as the hospital risk manager, providing risk identification and control through analysis of incident patterns and cases involved in litigation. This position oversees the function and impact of the HIM department and effectively plans and coordinates the acitivities of HIM, Joint Commission and other regulatory agencies. Communicates needs and revised program objectives to hospital management to maintain the Risk Management Program.
Primary Duties and Responsibilities
Minimum Qualifications
Education
- Master's degree in administration or healthcare related field. required and
- Knowledge of continuous quality improvement, processes and methodologies, Joint Commission Standards and CMS Conditions of Participation. required
Experience
- 3-4 years In accreditation /regulatory affairs/performance improvement/patient safety in health care. required and
- 5-7 years Managerial experience required and
- Knowledge of risk/safety event reporting software preferred
Licenses and Certifications
- Certification in Quality preferred and
- Patient Safety Officer Certification preferred
Knowledge, Skills, and Abilities
- Ability to comprehend and follow the policies and procedures for MedStar Southern Maryland Hospital Center.
- Ability to read, write and speak or communicate in English to successfully accomplish the essential duties of the position.
- Ability to demonstrate ethical behavior that supports the hospital's mission, values and commitment to compliance with all federal, state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities.
- Exhibits professionalism, courtesy and excellent customer service, while interacting with patients, guests and co-workers.
- Ability to work effectively with people from a variety of culturally diverse backgrounds.
- Ability to maintain patient confidentiality, knowledge of risk management principles and issues regarding patient safety.
- Knowledge and skill to demonstrate strong leadership and management qualities (task completion, delegation, motivation, supervision).
- Knowledge of accreditation standards, health care regulations, performance improvement and methods, patient safety and policy formulation.
- Ability to work with a variety of disciplines and levels of staff across department and the health system is required.
- Effective organizational, oral and written communication skills, problem solving, program development, computer skills, strong leadership, and team building skills.
This position has a hiring range of $131,497 - $256,630
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