Manager of Quality, Risk Management & Infection Control - NCCH

This positions REQUIRES current/unrestricted Registered Nurse License and BLS/ACLS/PALS/NIH Stroke Certifications (AHA) and completion of NIMS Courses (Refer to information below)

Summary: Functions as the Manager of Quality & Risk Management (MQRM) in a team and mission-based setting to provide responsibility for planning, organizing, and directing the overall operations of quality, risk management and employee health services/programs of a (small) Critical Access Hospital at Northern Cochise Community Hospital (NCCH).

MQRM is responsible for the development, coordination, implementation, and monitoring of activities or actions associated with the Quality and Risk Management plans. Develops and implements programs to promote employees’ health and safety on the job and meet regulatory and legal requirements for the maintenance of employee health records.

MQRM is responsible for creating an environment of patient-centered care through evidence-based standards. MQRM is accountable for formulating the departmental budget(s) and maintains efficient and effective departmental operations while meeting required compliance with all state, federal, and local regulation laws, standards, and protocols. MQRM oversees concern and complaint process regarding clinical care. Responsible for state and federal survey readiness.

MQRM manages and oversees the department for Quality, Risk Management, Infection Prevention, and other specific areas as may be assigned. MQRM assures competency of department(s) assigned personnel for education, skills, and compliance monitoring. MQRM collaborates with other NCCH departments such as Nursing, Rehabilitation Services, Radiology/Imaging, Respiratory Services, Laboratory, Revenue Cycle, Rural/Specialty Clinics and Emergency Preparedness/Safety teams to ensure appropriate patient care, quality metrics, and services are being performed. MQRM drives the Performance Improvement and Continuous Quality Improvement (CQI) program.

The Manager of Quality & Risk Management must possess strong leadership qualities that instill trust and accountability for a successful outcome.

NOTE: MQRM is subject to on call and call back as needed. Position requires collaborative rotation for weekend/after-hours call in nursing units, in NCCH administration and shift coverage for increased census/acuity or staff storages. MQRM is expected to and must be willing to work shifts in all areas of nursing clinical departments. Position is Safety Sensitive / Drug Free Workplace / Vaccination Requirements.

Supervision Required: Works under the direct supervision of the Chief Executive Officer (CEO) or designated administrator.

Reasonable Accommodations / Job Performance:

To perform this job successfully, an individual must be able to perform each essential function and the physical demands satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.   This job description outlines those functions, responsibilities, and success factors upon which the incumbent’s performance may be evaluated.

 Education and/or Experience:

Bachelor of Science in Nursing (BSN) from an accredited school of Nursing or Degree in Health Services Administration required, or relevant experience in lieu of Bachelors. Masters of Science Degree in Nursing (MSN) or Health Services Administration preferred.

 3-5 years hospital direct care nursing experience required.

Additional minimum of 2 years’ experience in Quality Management preferred.

Minimum of 2 years employee health or occupational health experience, preferred.

Certificates, Licenses, Registrations:

• Current Unrestricted Registered Nurse, license in the State of Arizona required.
• Current Basic Life Support (BLS) Certificate (American Heart Association), required - must maintain current certification and recertify prior to expiration date.
• Advanced Cardiac Life Support (ACLS) Certification and Pediatric Advanced Life Support (PALS) Certification (American Heart Association), required - must maintain current certification and recertify prior to expiration date.
• NIH Stroke Certification (American Heart Association), required.
• Emergency preparedness training preferred to include Intermediate and Advanced Incident Management System. Completion of NIMS Courses 100, 200, 700 required or obtained within 30 days of hire - must maintain current certification.
• Certified Professional in Healthcare Quality (CPHQ) preferred.

This position description is designed to outline primary duties, qualifications and job scope, but is not intended to limit the incumbent nor Northern Cochise Community Hospital Inc., to only the work identified