The Vice President of Quality, Compliance and Risk is responsible for abstracting, interpreting and presenting data for assigned databases or registries with the objective of assisting the organization in demonstrating excellence in health and clinical outcomes. The Vice President of Quality, Compliance and Risk will also oversee all process improvement education and projects. Additionally, responsible for independently directing a continuing, comprehensive program of compliance throughout the organization and is responsible for completing all duties as assigned.

• Plans and oversees the operations of the Quality Management System as described by CMS/ accrediting body. Facilitates the retrieval, analysis, tabulation of data and follow-up for major aspects of the hospital-wide performance improvement plan.
• Oversees data collection, abstraction, measurement and analysis pertaining to regulatory and organizational performance requirements. Oversees the reporting of patient care benchmarks and measurements to federal and state authorities.
• Continues follow-up evaluations of data and organizational performance to ensure consistent improvement. Provides feedback to directors at all levels regarding trends and issues, in the effort to improve quality and eliminate risks. Assists leadership in designing quality management and process improvement programs within their departments.
• Assures hospital and medical staff compliance with federal, state and regulatory requirements for Performance Improvement and Quality Management.
• Is responsible for occurrence reporting system, monitoring and addressing, as appropriate, to all patient and employee safety issues. Responds to all patient complaints and grievances as required by CMS/ accrediting body.
• Assists with the ongoing systematic processes for medical staff quality and peer review processes. Assists the hospital and medical staff departments and committees in assessing internal data and comparative information to identify improvement priorities, develop plans for improvement, and measure the success of actions taken.
• Collaborates with the Executive Team, Clinical Leaders, Case Management staff, Infectious Surveillance staff and Medical Staff Services to coordinate the daily work flow for house-wide quality, compliance and risk with special emphasis on HCHAP scores.

Education:

• Bachelor’s degree in Business, Healthcare Administration, or a clinical healthcare field or a combination of education and equivalent work experience is required.
• Master’s degree in hospital administration, or business administration, or a relevant field of study preferred.
• Minimum of two (5) years’ leadership experience in a healthcare environment required.
• Minimum of five (5) years’ clinical experience as an acute care RN and knowledge of laws, rules and regulations of the Medicare Conditions of Participation is required.

Required Licensure/Certification(s):

• Current RN license to practice professional Nursing in the State of New Mexico or acceptable compact state RN licensure required.
• CPHQ strongly preferred.
• Certificated Professional Healthcare Risk Management (CPHRM) required.