Middle Park Health
Director of Quality, Risk, Accreditation, EM, and Privacy
Middle Park Health, Denver, Colorado, United States
Director of Quality, Risk, Accreditation, EM, and Privacy
Director of Quality, Risk, Accreditation, Emergency Management and Privacy Officer
Position Purpose Under the direct supervision of the Chief Nursing Officer (CNO), the Director of Quality/Accreditation/Risk/Emergency Management (EM) and Privacy Officer will develop and implement programs designed to assess and review the quality and safety of patient care. Maintains appropriate records and ensures adherence to guidelines and coordinates all aspects of MPH Risk Management programs. Assists, coordinates, and leads efforts related to maintaining regulatory and community standards regarding Emergency Preparedness. Acts as Privacy Officer for Middle Park Health (MPH)
Essential Job Duties Quality/Regulatory
Initiates and oversees the development of a comprehensive quality improvement program; directs and coordinates in conjunction with the medical staff and executive leadership the quality initiatives for MPH.
Fosters and maintains collaborative relationships with external agencies and other stakeholders related to initiatives.
Oversees a comprehensive patient satisfaction program in efforts to improve the satisfaction of patients, visitors, and employees and makes recommendations for performance improvement activities.
Oversee all quality / regulatory and performance improvement activities.
Reviews and evaluates services that are affected by quality/regulatory issues, identifies problems, makes recommendations for improvement, and monitors services to ensure that quality/regulatory recommendations are implemented and the desired results are obtained.
Serves as resource for performance improvement, quality assurance, patient satisfaction, and regulatory issues.
In collaboration with Directors, participates in the development, monitoring, reporting, and improvement activities.
Works with the quality management on all reports and reviews all data obtained.
Ensures MPH is meeting all required quality data reporting to Federal and State agencies. Looks for new opportunities for reporting.
Coordinates the Quality and Patient Safety committee. Provides reports of the committee to CNO, Medical Staff, and the Hospital Board of Directors.
Oversee any state or regulatory surveys to ensure compliance with standards and make sure the necessary follow up is completed in a timely manner to the survey organization.
Risk
Monitor compliance with action recommendations and directives from authorized sources
Review incident/occurrence reports on a daily/weekly basis and report to Quality and Patient Safety committee
Acts as the hospital malpractice claims liaison with legal representatives
Establish, implement and coordinate MPH Risk management program
Works with department directors to handle all patient complaints and grievances. Collaborates with other departments involved to come to a satisfactory resolution. Communicates in a timely manner with all parties involved in a complaint.
Performs annual Risk assessment
Coordinates the Risk Committee meeting and makes sure senior leadership is aware of risk events.
Emergency Management
Responsible for coordination and implementation of emergency management standards to facilitate a safe environment for patients, staff, and visitors. Work on corrective action plans and improvement initiatives
Coordinate education and exercises within the organization to ensure an organized response during a disaster.
Work with Incident command during any incident and event response.
Conduct an annual hazard vulnerability assessment (HVA)
Develop and maintain emergency plans and procedures for disasters identified in the HVA/risk analysis.
Privacy Officer
Develop, implement, and maintain MPH’s HIPAA Privacy policies, revise as needed.
Handle all patient privacy complaints in accordance with MPH’s complaint procedure.
Mitigate the effects of any unauthorized use or disclosure of PHI or other Privacy and Security violations.
Train all appropriate staff regarding HIPAA rules and processes.
Leadership
Develops annual operating and capital budgets. Oversees the department(s) expenses to stay within budgetary constraints and obtain approval for exception items.
Manages and direct the department’s administrative functions.
Demonstrates problem-solving and trouble‑shooting skills; flexibility, organization formulates and recommends solutions.
Demonstrates an ability to be flexible, organized and a high degree of professionalism and confidentiality and ability to function in stressful situations.
Position Supervises Quality, Risk and Accreditation staff members
Degree of Supervision Provided CNO provides oversight and direction as needed. Must be self-directed, able to work independently and coordinate workload with other members of the department.
Requirements
Associate or Bachelor’s Degree in nursing required and Master’s in the field of nursing preferred.
Experience in Quality, Risk, Accreditation or Emergency Preparedness- preferred
Ability to organize, complete state reporting and coordinate projects.
Administrative and office management experience – preferred.
Compensation From $104,000+ per year based on experience. This position is eligible for a yearly incentive.
Benefits Comprehensive benefits available: PTO, Health, Vision, Dental, Life, FSA, HSA, Retirement, Employee Discounts and more.
To apply please submit resume and application to jobs@middleparkhealth.org. For more information or to inquire please call/text 970-457-6607
#J-18808-Ljbffr
Position Purpose Under the direct supervision of the Chief Nursing Officer (CNO), the Director of Quality/Accreditation/Risk/Emergency Management (EM) and Privacy Officer will develop and implement programs designed to assess and review the quality and safety of patient care. Maintains appropriate records and ensures adherence to guidelines and coordinates all aspects of MPH Risk Management programs. Assists, coordinates, and leads efforts related to maintaining regulatory and community standards regarding Emergency Preparedness. Acts as Privacy Officer for Middle Park Health (MPH)
Essential Job Duties Quality/Regulatory
Initiates and oversees the development of a comprehensive quality improvement program; directs and coordinates in conjunction with the medical staff and executive leadership the quality initiatives for MPH.
Fosters and maintains collaborative relationships with external agencies and other stakeholders related to initiatives.
Oversees a comprehensive patient satisfaction program in efforts to improve the satisfaction of patients, visitors, and employees and makes recommendations for performance improvement activities.
Oversee all quality / regulatory and performance improvement activities.
Reviews and evaluates services that are affected by quality/regulatory issues, identifies problems, makes recommendations for improvement, and monitors services to ensure that quality/regulatory recommendations are implemented and the desired results are obtained.
Serves as resource for performance improvement, quality assurance, patient satisfaction, and regulatory issues.
In collaboration with Directors, participates in the development, monitoring, reporting, and improvement activities.
Works with the quality management on all reports and reviews all data obtained.
Ensures MPH is meeting all required quality data reporting to Federal and State agencies. Looks for new opportunities for reporting.
Coordinates the Quality and Patient Safety committee. Provides reports of the committee to CNO, Medical Staff, and the Hospital Board of Directors.
Oversee any state or regulatory surveys to ensure compliance with standards and make sure the necessary follow up is completed in a timely manner to the survey organization.
Risk
Monitor compliance with action recommendations and directives from authorized sources
Review incident/occurrence reports on a daily/weekly basis and report to Quality and Patient Safety committee
Acts as the hospital malpractice claims liaison with legal representatives
Establish, implement and coordinate MPH Risk management program
Works with department directors to handle all patient complaints and grievances. Collaborates with other departments involved to come to a satisfactory resolution. Communicates in a timely manner with all parties involved in a complaint.
Performs annual Risk assessment
Coordinates the Risk Committee meeting and makes sure senior leadership is aware of risk events.
Emergency Management
Responsible for coordination and implementation of emergency management standards to facilitate a safe environment for patients, staff, and visitors. Work on corrective action plans and improvement initiatives
Coordinate education and exercises within the organization to ensure an organized response during a disaster.
Work with Incident command during any incident and event response.
Conduct an annual hazard vulnerability assessment (HVA)
Develop and maintain emergency plans and procedures for disasters identified in the HVA/risk analysis.
Privacy Officer
Develop, implement, and maintain MPH’s HIPAA Privacy policies, revise as needed.
Handle all patient privacy complaints in accordance with MPH’s complaint procedure.
Mitigate the effects of any unauthorized use or disclosure of PHI or other Privacy and Security violations.
Train all appropriate staff regarding HIPAA rules and processes.
Leadership
Develops annual operating and capital budgets. Oversees the department(s) expenses to stay within budgetary constraints and obtain approval for exception items.
Manages and direct the department’s administrative functions.
Demonstrates problem-solving and trouble‑shooting skills; flexibility, organization formulates and recommends solutions.
Demonstrates an ability to be flexible, organized and a high degree of professionalism and confidentiality and ability to function in stressful situations.
Position Supervises Quality, Risk and Accreditation staff members
Degree of Supervision Provided CNO provides oversight and direction as needed. Must be self-directed, able to work independently and coordinate workload with other members of the department.
Requirements
Associate or Bachelor’s Degree in nursing required and Master’s in the field of nursing preferred.
Experience in Quality, Risk, Accreditation or Emergency Preparedness- preferred
Ability to organize, complete state reporting and coordinate projects.
Administrative and office management experience – preferred.
Compensation From $104,000+ per year based on experience. This position is eligible for a yearly incentive.
Benefits Comprehensive benefits available: PTO, Health, Vision, Dental, Life, FSA, HSA, Retirement, Employee Discounts and more.
To apply please submit resume and application to jobs@middleparkhealth.org. For more information or to inquire please call/text 970-457-6607
#J-18808-Ljbffr