Director of Quality, Risk, & Compliance

At Snoqualmie Valley Health, we're not just in the business of healthcare; we're in the business of empowering our community to live boldly and live well. Our commitment to excellence and innovation calls for team members who will build trust, obsess over excellence, lead innovation, and deepen connections within our community. We are guided by our core values, and we're looking for someone who can embody those principles as part of our dynamic and growing team.

Located in a trailblazing, adventure-loving town at the base of the Cascades, Snoqualmie Valley Health is an independent public hospital district serving a vibrant community that thrives on both adventure and connection. This is more than a job-it's an opportunity to be part of something bigger.

POSITION SUMMARY: Snoqualmie Hospital is seeking a dedicated and experienced leader to serve as the Director of Quality, Risk, and Compliance reporting to the Chief Nursing Executive (CNE). This pivotal role is instrumental in fostering a culture of patient safety, continuous improvement, and regulatory excellence, ensuring the highest standards of care for our community.

This role focuses on managing quality programs, collaborating with clinical leaders, and driving operational changes to improve patient outcomes. The Director maintains strict adherence to regulatory compliance by overseeing key quality, risk, and compliance activities within the organization. This position is responsible for identifying trends, prioritizing and recommending improvements for all hospital departments. The successful applicant will provide quality improvement (QI) leadership and consultative services for the hospital and medical staff in effectively achieving regulatory success and organizational compliance for QI activities. The Director will organize and coordinate hospital certification standards and surveys, drafting and revising policies and procedures relating to the quality, compliance and risk programs. The ideal candidates will bring a wealth of experience in survey preparation, distinguishing themselves as Subject Matter Experts in quality and fully support a culture of safety within the organization.

ESSENTIAL FUNCTIONS: Be BOLD!

B - Build Trust: We exhibit integrity, transparency and compassion in every interaction.

O - Obsess Over Excellence: We have high standards and seek continuous improvement.

L - Lead Innovation: We lead with creativity, agility and think bold in our approach.

D - Deepen Connections: We build strong relationships with our patients, their families and partners in the communities we serve.

Essential Functions for this role supporting our BOLD Values.

• Oversee and manage the hospital's Quality, Risk Management, Compliance, Patient Relations, and Infection Prevention programs.
• Maintain and implement the District-wide Quality Plan, ensuring alignment with regulatory standards and organizational goals and report the status of the Quality Program to the Board of Commissioners;
• Serve as a resource for quality improvement (QI) initiatives, providing leadership, education, and guidance to hospital staff and medical personnel.
• Develop and direct strategies for compliance, risk management, and quality improvement to achieve regulatory accreditation and operational excellence.
• Monitor and report on quality metrics, patient experience data, and process improvement initiatives, integrating the "voice of our customers" into decision-making.
• Facilitate and chair relevant committees, including the Patient Safety and Quality Metrics Sub-Committee, to drive a culture of safety and performance improvement.
• Oversee the patient complaint and grievance processes. Ensures compliance, documentation, follow up, service recovery and process improvement related to patient feedback.
• Investigate and address incident reports, and care issues, providing resolutions and recommendations to prevent future occurrences.
• Oversee patient experience processes and metrics to ensure quality and satisfaction.
• Assure that the "voice of our customers" is incorporated in quality improvement activities by analyzing patient satisfaction survey or other patient care-related data.
• Lead efforts to educate staff on state and federal regulations and best practices in quality, risk, and compliance.
• Build and maintain strong relationships with all stakeholders, including patients, families, employees, and external regulatory bodies.
• Prepare and distribute reports that provide adequate information for departmental and leadership decision-making.
• Assist department managers in identifying and prioritizing opportunities for improvement in alignment with annual District Quality Goals
• Assist managers in event management review and processing, and selecting appropriate and effective corrective actions for patients, staff, and facility safety issues reported.
• Ensure confidentiality of all quality-related data and provide reports to the Board of Commissioners.
• Ability to function under stressful situations and cope with high levels of activity and multiple responsibilities.

QUALIFICATIONS:

Required Education: Bachelor's degree required in Professional clinical discipline, such as, but not limited to, Nursing, Occupational or Physical Therapy, Laboratory etc.

Preferred Education: Advanced degree desirable in health care administration, quality management, adult learning, or other discipline with emphasis on outcomes assessment and data management.

Required Licensure:

Specialty Certification (preferred):

• CPHQ, Certified Professional Healthcare Quality
• CPHRM, Certified Professional in Healthcare Risk Management
• LEAN Six Sigma

Required Experience:

• At least 5-years professional healthcare experience
• At least 3-5-years' experience in quality assurance, quality improvement, or risk management
• Experience managing quality improvement activities such as process improvement, lean methodologies, quality system assessment
• Experience interpreting healthcare regulations and accreditation requirements and designing systems to meet them.
• Experience with customer service and patient relations
• Survey design as well as interpretation and communication of survey results
• Proficiency in data management, statistical methods, and effective communication across all organizational levels.
• Preferred experience working for a Public Hospital District/Critical Access Hospital and CMS certified Rural Health Clinic

Skills:

• Strong ability to maintain confidentiality, navigate complex situations, and express ideas effectively to groups.
• Experience utilizing EPIC EMR
• Group facilitation skills required
• Strong communication skills both written and verbal.
• Demonstration of strong strategic and change management leadership.
• Demonstrated ability to work with cross functional teams to achieve organizational objectives.
• Ability to effectively interact with patients and families and deescalate stressful situations
• Problem solving and coaching in a team environment
• Computer skills including Microsoft Word, Microsoft Excel, Microsoft Visio, and on-line database management

WORK ENVIRONMENT:

• Office and clinical settings with potential exposure to patient care areas.
• Flexibility to work extended hours as needed.

PHYSICAL DEMANDS:

• Ability to work in a fast-paced environment and handle multiple priorities.
• May require occasional travel between facility locations.

OTHER DUTIES: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

BENEFITS: We believe in taking care of those who take care of our community. We're proud to offer a comprehensive benefits package that puts your health and well-being first. With our flexible medical plan, you'll have access to multiple in-network tiers, including top-quality care from Snoqualmie Valley Health, Eastside Health, and First Choice/First Health providers. The best part? Anyone covered under our plan can receive care at SVH at no cost! It's all about giving you the options and support you need to experience life's great adventures.

• Medical
• Dental
• Vision
• Pharmacy
• Health Reimbursement Account (HRA)
• Life and AD&D
• Retirement Plan
• Employee Assistance Program (EAP)
• Flexible Spending Account (FSA)
• Travel Assistance & ID Theft Protection
• Pet Insurance
• Other Voluntary Benefits

Benefit Eligibility Requirements - Employees regularly scheduled at least 20 hours per week.

Employee Dependents - Your legal spouse or domestic partner; dependent children until age 26.

Waiting Period - 1st of the month from the date of hire.

PLEASE NOTE:
The COVID vaccine and flu shot (during flu season) are required for employment, with exemptions available for valid medical or religious reasons.
Snoqualmie Valley Health is a drug-free workplace. We complete drug screenings as a part of our onboarding process.