As a compassionate non-profit organization since 1983, Chapters Health System is committed to enhancing the lives of those affected by advancing age or illness. Through our comprehensive system of healthcare choices, we deliver expert care and heartfelt support to guide the community during the aging and end-of-life journey. From hospice and palliative care for adults and children suffering with life-limiting illnesses to in-home and community-based services for frail but independent seniors, Chapters Health offers a wide range of support services along life’s ever-changing landscape. We’ll help you navigate your individual experience – empowering you with more choices, education and guidance for these important chapters of life.
The Director of Compliance, Quality and Risk is responsible for helping to create an environment and culture that enables the health system to fulfill its mission by meeting or exceeding its goals, conveying the mission to all staff, facilitating staff accountability for their performance, and motivating staff to improve their performance.
The Director manages, directs and plans all aspects of Compliance, Quality and Risk Management. The Director is responsible for a health system-wide quality management program and works with subsidiary leadership, departments and the medical staff to monitor and evaluate the quality of delivery of patient care services. The Director also ensures proper compliance with regulatory agencies, accrediting bodies, corporate and subsidiary policies and practice guidelines and works to develop, implement, and maintain quality assessment and improvement programs.
Job Specific Responsibilities:
- Provides information to the Chief Compliance & Clinical Officer on the implementation and management of patient safety event reporting and risk management/legal issues.
- Communicates in an effective and timely manner to appropriate individuals, the occurrence of known medical and healthcare adverse events, errors and dangerous conditions, as well as actions taken either proactively or based on occurrences.
- Works with other disciplines and departments to develop statistical reports.
- Integrates Compliance, performance improvement, patient safety and Joint Commission activities for the organization.
- Leads implementation of system-wide training efforts that focus on patient safety and risk management.
- Leads implementation and management of systems, including electronic tools, to facilitate appropriate reporting of unsafe circumstances, adverse events, errors or other adverse trends.
- Helps develop health system wide culture of safety and serves as Patient Safety Officer.
- Develops and maintains a Quality Assessment and Performance Improvement (QAPI) resource manual and TJC readiness Manual.
- Plans content and assists in the orientation of administrative staff and others.
- Assures standards and regulations are met.
- Compiles reports for the Board of Directors and the organization.
- Maintain knowledge of the latest national developments in patient safety and risk management and identifies best practices for health system.
- Plans and conducts ongoing compliance, quality, and risk assessments.
- Manages departmental and organizational projects.
- Promotes the Post Acute Care (PAC) concept in the community by participating in the development of educational materials and offerings for both the public and medical community.
- Assists Chief Compliance & Clinical Officer with compliance and other organizational issues
- Assures effectiveness of an ongoing Joint Commission readiness program.
- Oversees AHCA and Medicare surveys or inquires.
- ?Enhances professional expertise through attendance at national, state and local conferences.
- Presents at relevant professional or specialty organizations and participates at local meetings and national presentations.
- Maintains current certifications and licensure.
- Oversees on-going development and implementation of Electronic Health Record (EHR) to ensure adherence to regulatory requirements.
- Conducts audits to ensure compliance with established standards and processes.
Policy and Procedures
- Oversees compliance with regulatory agencies to meet standards and approve organizational practices.
- Assist in development of new Administrative Policies, Procedures or Corporate Practice Guidelines for implementation by each business entity.
Apply online at www.chaptershealth.org