Who We Are:

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Valley View Medical Center is a state-of-the-art hospital, licensed with 52 medical/surgical beds, 16 emergency department beds, 12 acute rehabilitation beds, 12 intensive care beds, 6 major operating rooms and 2 endoscopy suites plus a modern cardiac catheterization and 8 delivery & post-partum unit with all private bed hospital in the area.

Where We Are:

The Tri-State area has sunshine almost every day of the year. The beautiful clear skies, breathtaking sunsets on mountains to the east and west of us, and a mixture of the Great Outdoors along Arizona’s West Coast (the Colorado River) plus bountiful indoor activities provide something to do for everyone of any age.

Why Choose Us:

• Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
• Competitive Paid Time Off / Extended Illness Bank package for full-time employees
• Employee Assistance Program – mental, physical, and financial wellness assistance
• Tuition Reimbursement/Assistance for qualified applicants
• Professional Development and Growth Opportunities
• And much more…

*Position Summary: The Director of Quality and Risk Management provides comprehensive assessment, planning, monitoring and evaluation for compliance with accreditation, regulatory agency standards, performance improvement, quality of care and risk management. Participates in Valley View Medical Centers' (VVMC) Culture of Safety, Leapfrog and Duke LifePoint National Quality Program.

The Patient Safety Officer is responsible for day-to-day management of the Hospital's participation with LifePoint PSOrg, LLC, including collecting and assisting designated hospital personnel with collecting patient safety information and reporting it to LifePoint PSOrg, LLC on an ongoing basis for analysis and feedback. *

Promotes the mission, vision and values of the organizationDevelops and implements departmental goals, plans, and standards consistent with the clinical,administrative, legal, and ethical requirements/objectives of the organization.

Directs and evaluates departmental operations, including patient care delivery, information technologies, service level determination, and complaint management, to achieve performance and quality control objectives.

Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary actions, and continuing education initiatives within the quality department.

Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates in compliance with allocated funding.

Coordinates and directs internal/external audits.

Creates and fosters an environment that encourages professional growth.

Ensures department stays focused on their important role in the continuum of care.Directs and coordinates ongoing professional performance and evaluation

Quality ProgramDirects and coordinates accreditation initiatives; serve as the system liaison with The Joint Commission and other pertinent regulatory agencies focused on clinical care and patient safety.Provides overall direction necessary to ensure that services are provided in accordance with The Joint Commission accreditation standards and Medicare Conditions of Participation.Assesses compliance with accreditation standards and regulations in collaboration with leadership and staff.Analyzes compliance with accreditation standards and policies through the evaluation of information.Identifies areas of vulnerability related to accreditation standards and regulations.Analyzes policy for internal consistency and compliance; ensure optimal compliance with accreditation requirements.Serves as an expert resource on accreditation and regulatory issues to staff and physicians.Communicates requirements and standards in a timely manner to leadership .Translates standards, requirements and policies into terms or processes meaningful to the staff.Directs formulation of responses to accreditation findings and inquires.Provides consultation to relevant task forces, quality action teams and committees to insure ongoing compliance with standards.Participates in the organization’s quality improvement programs and processes.Assists with data collection and analysis for assigned areas.Provides training, define methodologies and promote support for best practices and evidence-based patient care.Ensures public reporting requirements are achieved and performance of the organization is communicated.

Risk ProgramThe Risk Management Program is designed to protect the human and financial assets of the organization against the adverse effects of accidental losses, effectively managing the losses that may occur, and enhance continuous improvement of patient care services in a safe healthcare environment.The Director is responsible for overseeing and coordinating the the facility’s risk management activities, which includes analyzing risk management data, trending, identifying gaps in results or program aspects, identifying opportunities for improvement, preparing reports to communicate data findings and analysis of information; conducting education applicable to risk management and patient safety initiatives.Complies with regulatory and accreditation standards; formulating policy to support risk management initiatives and principles; participating in committees to integrate risk management into committee work product; interfacing with the corporate risk management department on claims management; and minimizing loss to protect the assets of the facility.Collaborates with the Chief Nursing Officer (CNO) and Quality Coordinator (s) in the investigation of clinical events including sentinel events, sentinel event near misses, and significant adverse events. Leads and/or participates in the development of root cause analyses (RCA) as directed by the CNO.The Director is responsible for reviewing and formulating policy or organizational changes and making recommendations for final approval by senior management, medical staff and the board of trustees.The governing body has the ultimate responsibility to assure the provision of a safe environment. The governing body delegates authority for the establishment of a comprehensive, organization-wide risk management program to the hospital administration.The Director prepares reports for the governing body at least annually to report losses experienced, risk management program initiatives and effectiveness of the risk management strategies employed.Develops and oversees processes for internal SIM incident reporting, reviews SIM reports and conducts follow up investigations as warranted.The position is responsible through direct reports for patient advocacy through the grievance policy

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position. This position description does not restrict the right of management to assign or reassign duties and responsibilities with and without notice.To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.

Patient SafetyOversees the facilities patient safety program, develops and maintains a written patient safetyplans and annual evaluation of the plan’s effectiveness and develops and maintains policies andprocedures related to the patient safety program.The PSOrg Contact will further ensure that patient safety work product (PSWP is appropriately labeled and submitted to the patient safety evaluation systems (PSES, and reported back to LifePoint PSOrg as appropriate.The Patient Safety Officer will assist with the facility's patient safety plan, and internal dissemination of patient safety information. Ensures the development of surveillance systems to identify and mitigate potential patient harm.Liaison for the National Quality Program through Lifepoint.The Patient Safety Officer assists with the education of appropriate staff as well as medical staff related to the purpose of the PSOrg, maintains an ongoing working relationship with the PSOrg for patient safety improvement efforts, oversees the reporting process to LifePoint.The Hospital's PSOrg contact has the primary responsibility for communicating with the LifePoint PSOrg, LLD staff, managing the Hospital's participation in the PSOrg in collaboration with the Hospital's administrative team, leading various meetings involving the PSOrg participation and analysis, and providing oversight for communication plans for the hospital in conjunction with the LifePoint PSOrg, LLC.The hospital PSOrg contact provides leadership to the hospital and its staff related to furthering a culture of patient safety and quality and focused on reduction harm to patients within the hospital.Develops and implements initiatives to create an appropriate patient safety culture using transparency as the foundation of this effort. Educates frontline staff, directors, managers on LifePoint's Mission, Vision and Foundational Five

Professional RequirementsCompletes annual education requirements.Maintains regulatory requirements, including all state, federal and The Joint Commission regulations.Establishes/maintains good relationships with the CEO, CNO, CFO and department leaders to promote a cooperative and constructive environment for improvement.Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.Promotes excellence in internal and external customer service by maintaining consistent, timely communication regarding all facets of departmental activities with his/her team.Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomesEnsures compliance with policies and procedures regarding department operations, fire, safety and infection control.Effectively and consistently communicates administrative directive to personnel and encourages interactive departmental meetings and discussions.Acquires and maintains National Certified Professional in Patient Safety credential within TWO (2) years of hire.

Minimum EducationX High school diploma or equivalent x Preferred X Associate’s degree □ Preferred X Required X Bachelor’s degree □ Preferred X RequiredGraduate of an accredited program for registered nurse. X Master's degree X Preferred □ Required

Minimum Work ExperienceProgressive Management responsibility/leadership responsibility in an acute care setting preferred.Knowledge of Joint Commission standards with a minimum of 3 years experience in a clinical or administrative management role.

Required SkillsRequires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.Strong leadership and negotiation skills.Effective communication, both verbally and in writing. Certifications:X Basic Life Support (BLS) - American Heart Association X Required(If ACLS is obtained, BLS is not required)X Certified Professional in Patient Safety (CPPS) certification X Requiredwithin TWO (2) years of hire.

Required Licenses[Arizona, United States] Registered Nurse Valid RN licensure in good standing. Multi-State Licensure accepted.

Job: *Quality

Organization: *Valley View Medical Center

Title: Director Quality & Risk Mgmt - FT Days

Location: Arizona-Ft. Mohave

Requisition ID: 7451-3450