Greater opportunities to build the life you want
Greater Peoria, IL
Greater Peoria, IL

Director Quality, Safety and Risk- CMH BH Admin



Quality Assurance
Peoria, IL, USA
Posted on Friday, June 2, 2023

Job Description


The Director of Quality, Safety and Risk serves as a highly visible champion of quality and patient safety throughout TrilliumPlace. Works closely with the President, Executive Directors and Directors, and Chief Medical Officer to provide leadership efforts to continuously improve the quality and safety of care. Leads the organization to achieve outstanding performance on key, nationally standardized metrics of quality and safety. This position directs, plans and implements the Performance Improvement Plan, the Patient Safety Plan, Risk Management Plan, Accreditation efforts and Clinical Data Management for TrillimPlace. This position plans, organizes and directs the department/staff responsible for patient safety, environment of care safety, data collection and presentation, and regulatory compliance. In addition, this position plans, organizes and directs the department/staff responsible for the Risk management program, event management and claims management personnel.

  • Master's Degree in the field of Nursing, Healthcare Administration or Business Administration
  • 5-7 years of experience in/with prior experience which demonstrates clinical and leadership competence. It is imperative that the person have an excellent understanding of current trends and issues in the professional practices of multiple disciplines. Successful performance of the position’s accountabilities requires effective leadership skills, ability to prioritize multiple demands, and in-depth patient care knowledge.
  • Current licensure in good standing as a Registered Nurse in the State of Illinois.
  • CPHQ
  • Outstanding listening, interpersonal relationship building, and problem-solving skills
  • Exceptional level of professionalism, discretion and the ability to work on highly sensitive and confidential projects
  • Able to prioritize and manage multiple projects simultaneously with demonstrated ability to complete projects successfully on time and within budget
  • Knowledge of current trends and best practices in healthcare quality improvement and patient safety
  • Highly developed skills using personal computer tools including MS Office

  • Develops the organizational PI plan and the steps to implement the plan across the organization to assure a systematic, consistent approach to PI across the continuum. The plan supports organizational strategies/objectives and PI initiatives are based upon the service line needs.
  • Develop and implement strategies to integrate plan and indicators within the organization, ensures effectiveness of the plan implementation, educates the organization on the plan and indicators as appropriate.
  • Facilitates reporting of performance improvement activity through a variety of channels including Senior Leadership Meetings, Leadership Meetings, etc. Evaluates indicators in appropriate committees, departments, etc.
  • Works with all Service Lines and departments as they plan, develop and implement PI projects in their areas. Ensures collaboration and integration of all key customers.
  • Serves as educator, facilitator, and internal consultant to the Board, Senior Leadership Team, Quality Council and departments throughout TrilliumPlace
  • Maintains current understanding of the healthcare environment, including regulatory reporting environment, pay for performance, community measurement, accountable care organizations, and quality reporting.

Patient Safety

  • Collaborate with clinical staff to develop, implement, monitor and champion performance improvement processes and policies related to key patient safety issues.
  • Coordinate efforts of various departments/stakeholders related to patient safety, share the experience/learnings with others through professional presentations, publications, etc.
  • Oversees the collection and dispersion of information related to patient safety through monitoring and reporting performance relative to patient safety indicators.
  • Oversees organizational Patient Safety Initiatives including thorough and credible root cause analysis which lead to organizational learning.
  • Oversees the development and implementation of plans to position TrilliumPlace as a leader in patient safety.
  • Fosters a culture within TrilliumPlace that promotes prevention, detection, and resolution of conduct that does not conform to established standards, regulatory requirements, and TrilliumPlace ethical and business policies.

Risk and Regulatory

  • Develop and implement annual Risk Management plan
  • Plans and oversees regular, periodic audits of high risk activities and operations in order to identify and rectify any possible barriers to the efficacy of the Risk Management Program.
  • Collaborates with legal counsel routinely in areas of legal risk.
  • Review the reporting of overpayments in concert with legal & Senior Management review.
  • Directs, plans, and coordinates organizational wide compliance with current standards of TJC, IDPH, SUPR, BOP, and other regulatory bodies to ensure ongoing compliance or active progress towards compliance.
  • Assures that medical staff components for Joint Commission and other regulatory agencies are in compliance for accreditation.