Director of Quality and Risk Management
- Lead the hospital's Quality Assessment and Performance Improvement (QAPI) program in accordance with CMS Conditions of Participation and accreditation standards.
- Develop, monitor, and report quality metrics relevant to inpatient psychiatric care.
- Analyze quality and risk data to identify trends and opportunities for improvement.
- Facilitate performance improvement projects, including root cause analyses and action plans.
- Prepare quality reports for executive leadership, medical staff, and the Governing Body.
- Direct the hospital's risk management program, including incident reporting, investigation, tracking, and follow-up.
- Oversee review and response to adverse events, near misses, and sentinel events.
- Coordinate Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA).
- Monitor behavioral health–specific risks such as suicide/self-harm, elopement, aggression, restraint and seclusion, and environmental safety.
- Partner with leadership to implement risk reduction strategies and corrective action plans.
- Ensure compliance with CMS Conditions of Participation, state licensing requirements, and accreditation standards.
- Serve as the primary point of contact for regulatory surveys and inspections.
- Coordinate survey preparation, on-site support, and post-survey corrective actions.
- Maintain policies, procedures, and documentation related to quality and risk.
- Track regulatory changes and communicate impacts to leadership.
- Promote a culture of safety, transparency, and continuous improvement.
- Support staff education related to quality and patient safety.
- Encourage incident and near-miss reporting using just culture principles.
- Provide consultation to department leaders on quality and risk concerns.
- Collaborate with the CEO and department leaders to align quality initiatives with organizational goals.
- Participate in leadership and quality committees.
- Provide oversight to quality and risk staff, if applicable.
- Bachelor's degree in Healthcare Administration, Business Administration, Public Health, or related field required.
- Master's degree preferred.
- Two (2) years of progressive experience in healthcare quality improvement, risk management, compliance, or performance improvement preferred.
- Behavioral health or inpatient psychiatric experience preferred but not required.
- Knowledge of healthcare quality and risk management principles.
- Strong analytical, organizational, and problem-solving skills.
- Effective written and verbal communication skills.
- Ability to collaborate with multidisciplinary teams and executive leadership.
- Professional judgment and discretion.
- Ability to work in an inpatient psychiatric hospital environment.
- Ability to sit, stand, walk, and move throughout the facility.
- Flexibility to work additional hours during surveys or investigations.
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