Bryan Health

1.*Commits to the KRMC mission, vision, values and goals and consistently demonstrates our core values.

2. *Responsible for assigned areas including risk management, patient safety, compliance, legal, claims coordination, and patient experience oversight.

3. *Oversees the departmental budgetary procedure to ensure proper operational and capital planning, appropriate and efficient use of resources, and consistent compliance to budgetary and fiscal controls.

4. *Responsible for hiring, training, supervising, coaching, mentoring, retaining and evaluating of staff.

5. *Manages and provides accountability for the operational aspects of risk management and patient safety, including oversight of event review and triage, coordination of root cause analysis (RCA) and internal investigations, claims coordination, management of subpoena and claims documentation, privacy incident coordination, grievance management, service recovery, and safety rounding.

6. *Leads the adoption and sustainment of the Bryan Health Improvement system for KRMC in areas of responsibility to achieve service excellence, sustainable capability, and a culture of continuous improvement.

7. *Supports system-wide regulatory, accreditation, and contracted compliance requirements, survey readiness and timely resolution of corrective/improvement actions.

8. *Maintains current knowledge of applicable accreditation, compliance, and contracted agency/program and industry standards, and monitors advancements to ensure organizational adoption and compliance.

9. *Leads or participates in governance groups and improvement initiatives or teams as assigned.

10. *Manages the required clinical data retrieval, analysis, and submission to external agencies and promoting interoperability program.

11. *Facilitates the use of statistical and other analytic methods to analyze and inform decisions and validation of outcomes for quality improvement teams/projects and governance groups.

12. *Oversees the benchmarking of quality and patient safety measures against internal and external groups.

13. *Manages system-wide process for controlled document management (procedures) and process change control.

14. *Consults with divisions, services lines and teams for the identification, improvement, and sustainment of quality and patient safety opportunities, compliance requirements, measures, and internal standards including Infection Prevention, Patient Experience, and Risk.

15. *Collaborates across the organization to maintain an effective data governance lifecycle and data analytics capabilities that support effective operations and improvement.

16. Supports the development and maintenance of internal standards (procedures, order sets, work instructions.

17. Assists in the development, implementation, and ongoing assessment of the quality and safety plan.

18. Participates in product/software evaluation studies and consequent decision-making activities.

19. Supports the identification, validation and effective spread of locally proven system capability.

20. Develops and delivers training and information to the organization on quality-related topics.

21. Develops communication plans and communicates extensively with key stakeholders; crafts messages, presentations and reports tailored to the appropriate target audience and desired outcome.

22. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

EDUCATION AND EXPERIENCE:

Bachelor’s degree in nursing, allied health, business, engineering, or a related field required. Master’s degree preferred. Minimum of five (5) years of progressive experience in quality, performance improvement, or clinical operations and a minimum of two (2) years of supervisory or program management experience required. Advanced analytical skills strongly preferred, as is prior experience with regulatory surveys and compliance.

OTHER CREDENTIALS / CERTIFICATIONS:

Certification relevant to quality, safety, performance improvement, or project management preferred.