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Job Posting

Manager of Quality and Risk
Manager of Quality and Risk

St. Luke's Hospital Criteria Based Performance Standards, Hospital Policies, Joint Commission Regulations and various other laws/regulations require that we assess the ongoing competency of our staff to assure that the staff maintains competency to perform their duties proficiently. Competency evaluation may include tests for knowledge, demonstration of skills and direct observation of performance.

The Quality Improvement / Risk Manager of St. Luke's Hospital is a qualified individual with responsibility to plan, organize, direct, and lead the quality/performance improvement and risk reduction processes for the organization. Outstanding ability to collect, analyze and interpret both qualitative and quantitative data related to quality/performance improvement strategies and/or Lean initiatives to measure effectiveness of the quality, safety and improvement programs.

As Quality & Risk Manager, this person will be responsible for the risk reduction strategies and processes of the organization. The Quality & Risk Manager will ensure conformance to regulatory requirements, contractual obligations, and corporate policy as defined by the organizations policies and procedures, and in accordance with the overall quality and performance improvement programs. The Quality & Risk Manager is responsible for effective communication with Hospital Liability Insurance carrier to minimize risk of loss to organization.

St. Luke's Hospital Criteria Based Performance Standards, Hospital Policies, Joint Commission Regulations and various other laws/regulations require that we assess the ongoing competency of our staff to assure that the staff maintains competency to perform their duties proficiently. Competency evaluation may include tests for knowledge, demonstration of skills and direct observation of performance.

Required Knowledge, Skills and Abilities

Current RN licensure in the State of North Carolina or one of the Compact States.
BSN required. MSN or equivalent preferred.
Five years' experience in an acute care hospital.
Minimum three (3) years' experience in a supervisory position in healthcare or three (3) years Quality Improvement and/or Risk Management. Certification in Quality or Risk Management preferred.
BLS required.
Excellent communication skills. Proven ability to communicate effectively with all levels of the organization, members of the community, public authorities, and legal representatives—both verbally and in writing.
Demonstrates a proficient knowledge of project management, including computer hardware and software directed toward the management of database systems. Proficient in Outlook, Word, Excel, and Power Point programs
Systems-based orientation to process improvement and problem-solving. Familiar with principles of Just Culture
Performance Improvement methodologies and/or Lean processes.
Proven ability to navigate projects/process improvement activities successfully with both clinical and non-clinical stakeholders.
Demonstrates strong critical thinking and problem-solving skills.
Demonstrates interpersonal relationships in a manner that enhances communication, promotes conflict resolution, and facilitates staff development.

Essential Functions (including but not limited to):

Timely coordination/completion of data gathering and aggregation for submission to management company and VP Patient Care Services. To include, but not limited to inpatient and outpatient core measures, quality measures reporting as required, assistance with required reporting of infection control metrics, and standing reports to Senior leadership and the Board of Trustees and Quality Committee.

Facilitates and is liaison with medical records and third-party vendor (to assist with data mining for core measures, etc.); works with vendor to ensure data availability for timely reporting.

Develops and provides quality data and educational presentations for managers and administration in a meaningful format. Develops instructional materials for staff, patients and families. Evaluates/updates
presentation and teaching material through on-going feedback and suggestions.

Serves as internal expert for Performance Improvement Projects and information flow; works with customers to provide meaningful data to aid in improved outcomes and decision-making. Effectively communicates appropriate information and feedback in a clear, concise and timely manner to physicians, staff and administration.

Facilitates the executive team in the development and maintenance of organizational performance improvement priorities.

Coaches and supports the team to utilize the PDSA model. Coaches managers in the development of departmental or service-line performance improvement goals related to annual organizational priorities. Ensures follow up with stakeholders and works with organizational leaders, including medical staff, to hold stakeholders accountable for participation and outcomes. Provides leadership for implementing changes targeted at systems improvement. Measures and evaluates attainment of results.

Ensures that improvement activities are documented and reported within the organization and externally as appropriate.

Demonstrates current clinical knowledge as well as current knowledge of regulations and standards as relating to NCQA, TJC, CMS, or other appropriate regulatory agencies.

Studies current trends and remains current with new industry developments, teaching methodologies, and best practices through professional journals, seminars/conferences, professional societies, etc. Seeks ways to incorporate best practices into organizational policies and procedures.

Administers risk-management and loss-prevention programs. Demonstrates comprehensive knowledge of risk management strategies, program compliance and ability to work collaboratively with vendors and auditors.

Responsible for incident tracking system administration, ensuring completion of resolution and response to reporting parties, trending and reporting to Safety Committee. Acts as the liaison to attorneys, insurance companies and individuals, investigating any incidents that may result in asset loss.

Coordinates audits by the malpractice insurance carrier and ensures compliance with requirements. Reviews Confidential Incident Reports (CIRs) and handles all aspects of claims management.

Facilitates Root Cause Analyses (RCA), Healthcare Failure Mode Effects Analyses (HFMEA), and other risk assessment techniques. Oversees investigations into adverse clinical events, ensuring follow- up by appropriate persons or entities.

Keeps organizational Leadership abreast of issues that pose risk to the organization.

Demonstrates problem solving, leadership, conflict management, and team building skills in
order to ensure a productive work environment and achievement of goals. Maintains a good working relationship among departmental leaders.

Consults and assists other departments as appropriate to collaborate in patient care, infection prevention, utilization management, medical staff focused and ongoing practice evaluation, quality management and regulatory compliance activities.

Additional Information
Position Type : Full Time
Shift : Day

Contact Information
Rachel Wood - Administrative Director of Quality and Ambulatory Services

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