Duties and Responsibilities:

• Proactively maintains the organization in a “constant survey readiness mode”. Ensures the organization meets all accreditation, regulatory and quality standards for accreditation and licensing. Coordinates all survey activity within the organization.
• Collaborates with Senior Leaders, Managers and Medical Staff to develop and achieve quality, safety and risk management goals for the organization in alignment with the hospital’s strategic objectives and goals.
• Develops processes to proactively prevent risk issues. Investigates and takes appropriate timely action(s) to resolve patient family or other customer concerns, complaints, and problems. Manages potential and actual professional/clinical claims and suits related to the organization by acting as the liaison to the liability carrier, patient/family and involved practitioners.

• Develops and manages the organizations patient/visitor relations and occurrence reporting and follow-up programs (i.e., patient perception of care surveys, complaints, service recovery, disclosures).
• Conducts or coordinates concurrent and retrospective reviews of key indicators identified by the Medical Staff and other clinical disciplines to monitor and evaluate clinical care, safety and service.
• Proactively identifies and implements quality indicators to drive performance improvement. Collaborates with Medical Staff Coordinator to establish and implement a process for selecting criteria and monitoring data for focused and ongoing professional practice evaluations for the medical staff.
• Collaborates with the organization’s Corporate Compliance Committee and Officer to assure compliance with regulatory standards relating to utilization, business and quality management principles.
• Participates in quality, risk, patient safety, and regulatory orientation and educational in-services for employees and physicians including the overview of the Performance Improvement, Quality and Patient Safety Plans for the Organization.
• Collaborates with the Data Analyst to manage the quality, risk, and patient safety program’s data collection, analysis and reporting. Coordinates organizational data reporting requirements .