Regional Director of Quality and Risk

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Job Description

Encompass Health is currently looking for a Regional Director of Quality and Risk to help support our South East Region. This region consists of hospitals throughout Florida. This position will require about 75% travel.

The Regional Quality/Risk Director is responsible for helping to create an environment and culture that enables the region to fulfill its mission by meeting or exceeding its goals, conveying the company’s mission to all staff, facilitating hospital accountability for their performance, and motivating staff to improve their performance.  This position will support cultural diversity by ensuring that the delivery of quality, equitable and culturally competent patient-centered care is provided; and promoting and maintaining an inclusive work environment and culture that is respectful and accepting of diversity.


License or Certification:

  • Licensed or Certified according to individual state requirement


Education, Training and Years of Experience:

  • Bachelors degree in healthcare or related field preferred.
  • Quality and/or Risk Management experience including primary responsibility for performance improvement activities, regulatory compliance, conflict resolution, leadership and risk management activities.


Essential Job Functions:

  • Manages, directs, and plans all aspects of Quality and Risk Management throughout the region.
  • Develops and implements programs throughout the region and company, working with hospital administration, departments, and the medical staff to monitor and evaluate the quality of delivery of patient care services within the region.
  • Ensures proper compliance with regulatory agencies, accrediting bodies, corporate and hospital policies and procedures and works to develop, implement, and maintain quality assessment and improvement programs within the facility.
  • Conducts onsite assessments of hospital compliance with laws, regulations, and company policies, helping to develop appropriate action plans and remediation initiatives in areas not exceeding the standards.
  • Serves on the Quality Leadership Board through regular attendance on conference calls, meetings, and functions.
  • Assists local hospitals to and/or submits corrective action plans and assessments (i.e. TJC PPR) to regulatory and accrediting bodies within required timeframe and oversees oversight of corrective action plan through ongoing monitoring.
  • Compiles data in usable formats for analysis against appropriate benchmarks, using current statistical tools and techniques in an effort to identify improvement opportunities.
  • Facilitates committees and teams for performance improvement. Insures that the following PI teams are in place: falls PI committee, FMEA, and others per hospital priorities. 
  • Mentors others for the leader and facilitator role in the performance improvement process. Encourages others to serve as PI team leaders and facilitators.
  • Coordinates the review, revision, development, approval and implementation of hospital specific policies and implementation of Corporate policies applicable to the hospital and region.
  • Communicates and collaborates with other departments to coordinate care and promptly resolve customer concerns or complaints as outlined in the Corporate Patient Complaint/grievance Policy. 
  • Prepares and submits timely, statistically correct, complete reports of risk management and quality information to the appropriate hospital, regional, corporate, or external agency. 
  • Coordinates all RCA (root cause analysis)/sentinel event report development and reporting to required local, state, federal and accreditation agencies related to sentinel events and mortality as required by local/state/federal jurisdiction and/or accreditation agencies.
  • Assists local hospitals with the update and maintenance of hospital plans (for example Plan for the Provision of Care/Scope of Services, Leadership, Information Management, Utilization Review, Infection Control, Performance Improvement and Patient Safety).
  • Shares Patient Satisfaction data with leadership and regional team, identifying opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction.
  • Oversees risk management activities including completion of incident reports, notice of potential claims, corrective action planning and incident reporting to Corporate Risk Manager. Completes monthly online reporting to Corporate Risk Management within required timeframe.
  • Uses a variety of applications (including but not limited to PatCom, UDS, ORYX, and NRC Picker) to identify improvement opportunities, generate reports, research issues, identify resources, and access external databases
  • Oversees complaint process including complaint investigation; verbal and written complaint follow-up; corrective action planning; and maintenance of complaint log.  Insures verbal/written follow-up occurs within required timeframe and in accord with Corporate Risk Management policy.
  • Acts as an organizational liaison with the CEO and Corporate Compliance to insure implementation of the Standards of Business Conduct and all applicable compliance policies.
  • Maintains appropriate records and documentation of Quality Council, MEC, and Governing Body activities including minutes, supporting data, logs, and all related documents in accordance with state and federal law. 
  • Organizes, plans, and manages time effectively to complete assignments.
  • Meets position requirements and performs essential functions.
  • Reports questionable situations, concerns, complaints or harassment immediately.
  • Successfully completes all assigned training on or before due date and annual skills competency as determined by the hospital based on new responsibilities, specialized equipment, high risk/problem prone/or low volume procedures including emergency response techniques.
  • Reports questionable situations, concerns, complaints or harassment immediately.



Address: ,
Shift: Day Job
Schedule: Full-time
Job ID: 2022175