Responsibilities

• Directs, controls and evaluates the activities, functions, and management of personnel within the Quality/Performance Improvement, Risk Management, and Medical Staff Office departments as well as effectively managing and meeting fiscal goals defined for these departments.
• Responsible for facility-wide regulatory compliance. Serves as the Patient Safety Officer and Ethics and Compliance Officer.
• Achieves shared operational management among leadership, medical staff, and clinical employees to continually improve patient care outcomes.
• Implements the vision, goals, and strategies of the Senior Leadership team as a dynamic leader with excellent communication skills and the ability to motivate and continually advance clinical practice and patient experiences.
• Collaborates with physicians, clinical managers and other members of the health care team to coordinate activities between the hospital and physicians, promote optimum patient care/service, identify and resolve barriers, and promote growth in patient volume.
• Oversight and continued implementation of the Ethics & Compliance Program and the facility's compliance with requirements of federal health care programs.
• Conducts independent investigations on ethics and compliance issues and ensures all E&C standards and policies and procedures are communicated to each LifePoint colleague, agent and independent contractor according to the requirements of each position and then adhered to accordingly.
• Fosters and environment where colleagues know they can raise concerns or report suspected code violations.

Quality

• Facility oversight of performance improvement program.
• Facility oversight of regulatory and accreditation program.
• Facility oversight of risk management program.
• Facility oversight of patient safety program.
• Leads the Quality/Risk/Medical Staff Office Department within defined financial priorities.

Risk Management

• Conducts clinical risk assessments and analysis of complex organizational systems within the facility and facilitates development of corrective action plan.
• Formulates analysis plan for data management
• Oversees investigations of incidents that could lead to professional/general liability claims.
• Develops policies and procedures related to Risk Management.
• Disseminates information and research related to changes in regulatory requirements and clinical research pertinent to potential liability exposures and risk issues
• Consults with LifePoint PSOrg, LLC on all occasions when the Hospital receives a request for dissemination of PSOrg related information, as well as other PSOrg compliance related issues.
• Develops, implements and presents educational program for Employees, the Medical Staff and the Board
• Obtains a minimum of 15 hours of continuing education in Risk Management on an annual basis.
• Participates in review and development of committee structure and membership for facility.
• Devises quality report cards for Physicians and Advanced Practice Practitioners

Regulatory Compliance

• Oversees hospital-wide Quality and Performance Improvement program.
• Plans, organizes and implements performance improvement activities
• Plans and organizes Six Sigma team activities
• Provides for ongoing education on PI and Six Sigma processes
• Coordinates CMS/TJC Core Measures activities
• Plans, organizes, and implements Regulatory and Accreditation program
• Serves as contact person and liaison between the hospital and accreditation/regulatory agencies, both on a Federal and State level.

Ethics & Compliance

• Serve as Chair for the Facility Ethics & Compliance Committee.
• Conducting Investigations, encouraging Reporting without fear of retaliation and advising colleagues on E&C matters.
• Coordinating and supporting corporate monitoring and auditing procedures and establishing and maintaining formalized monitoring programs.
• Identifying trends related to ethics and compliance within the facility and participate in communication and interfaces with Service Center ECOs, Corporate Departments and other ECOs.
•  Serving as liaison to the facility's Senior Administration and Department Directors.