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Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The Clinical Quality and Safety Consultant works in collaboration with administrators, physicians, patient safety officers and other clinical team members to improve patient safety and quality. This individual is actively involved in working with the campus Patient Safety Officer and the campus Leadership Team to ensure that the organization is in a constant state of regulatory compliance. This consultant serves as a facilitator for projects and performance improvement teams utilizing a variety of PI methodologies embraced by the organization including Lean Six Sigma and Rapid Cycle Improvement. This individual shall adhere to all Florida Hospital policies/ procedures and rules / regulations of all applicable local, state and federal agencies and accrediting bodies. PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:• Demonstrates through behavior, Florida Hospital’s core values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork.• Demonstrates expert knowledge in quality and process improvement methodologies, systems thinking and patient safety; serves as a catalyst for change. • Performs data collection and analysis to identify opportunities for improvement• Serves as consultant to develop data collection tools• Utilizes literature and benchmarking resources in indicator development.• Provides data collection that is accurate and timely• Stratifies and aggregates data into meaningful information.• Displays outstanding creativity in development of measurement systems and acts as a resource for all customers served.• Creates reports and graphical presentations and effectively communicates issues and trends to administration and hospital / medical staff.• Prepares reports to support quality initiatives for assigned campus and system projects that are deployed throughout the organization• Develops reports on needed aggregate data accurately in a timely manner• Demonstrates creativity and a broad scope of knowledge in various data source programs• Utilizes regulatory knowledge and understanding of CMS, JCAHO, Title 22, and other State and Federal regulations to improve patient safety and quality• Utilize knowledge to assist or lead activities of continuous survey readiness• Conduct audits related to MOS and/or develop tools for auditing• Analyze audit data and identify opportunities for improvements• Applies advanced performance improvement skills to any team/committee or department PIT or PI project• Solutions Sessions• Change Acceleration Process (CAP)• Lean Six Sigma• Root Cause Analysis support (RCA)• Failure Mode Effects Analysis (FMEA)• Advanced statistical analysis• Facilitates and coordinates Patient Safety and PI projects in conjunction with campus administration, campus PSO, and the Office of Clinical Excellence.• Serves as consultant to campus Core Measure process owners• Assists with campus Joint Commission Periodic Performance Review• Supports Patient Safety Officer with NQF analysis• Participates in campus Patient Safety and Quality Committee by attending and presenting results of performance improvement teams, or other projects as assigned. Attends designated campus or system committees to support PI initiatives.• Prioritizes and organizes to meet deadlines for data analysis, team coordination, presentations and other assignments. RequirementsEDUCATION AND EXPERIENCE REQUIRED:• Degree in Nursing or other Health Care related field PREFERRED EDUCATION AND EXPERIENCE: • Bachelor or Masters Degree• 1-2 year’s management experience. • Minimum of three years acute care clinical experience• Experience in Healthcare quality/performance/process improvement• Lean/ Six Sigma trainingKNOWLEDGE AND SKILLS REQUIRED: • Minimum of three years experience in a clinical setting. Excellent interpersonal skills and ability to facilitate performance improvement teams required. Excellent written and oral communication skills. Basic computer skills such as Word, Excel, Power Point. PREFERRED KNOWLEDGE AND SKILLS:• Demonstrated leadership in the area of Performance Improvement.• Problem solving skills• Process Improvement skills• Project management experience LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:• Current Florida Nursing Licensure (RN) or other Health Care Professional License PREFERRED LICENSURE OR REGISTRATION:• Certification in Certified Professional in Healthcare Quality (CPHQ), Six Sigma Greenbelt, Healthcare Risk Manager

The Risk Management Director (RMD) serves as a key member of the facility leadership and is on the senior management team. The RMD has broad responsibility to protect the facility´s assets from loss. The RMD is responsible for coordinating the loss control efforts and advising management and administration on all potential sources of loss and for making recommendations to minimize or eliminate exposure. The structure and functions of the Risk Management Program are designed so as to comply with guidelines and standards of JCAHO, other regulatory agencies, and the UHS T.E.R.M. Program. The Risk Management Director plans, organizes and directs all activities in compliance with facility, state, federal and other accrediting and regulatory agency requirements. The individual in this role is responsible for coordinating the loss control efforts and making recommendations to minimize or eliminate exposure. The Risk Management Director functions in a manner consistent with the philosophy and objectives of Compass Intervention Center.Leadership:*Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices. *Assumes a leadership role in the Risk Management program. Measures outcomes of risk management functions and makes recommendations to Senior Management on risk management issues. *Performs research, statistical projects and studies for the medical staff, administration and other facility departments.*Participates in the Safety and Performance Improvement Council committees. Consultant to the Medical Staff Executive committees.Risk Management:*Develops Loss Prevention and Risk Management Education Program. Provides education to new employees at orientation and conducts ongoing education and in-services on risk management topics annually. *Promotes Critical Risk Prevention Techniques to ensure appropriate release of information, informed consent and confidentiality issues are in accordance with established facility policies and procedures. Reviews policies regularly.*Participates in Safety Committee as co-chair and conducts safety rounds with other committee members to identify hazards and makes recommendations for corrective action.*Receives quarterly reports and evaluates corrective actions. Reports results of monitoring and evaluation activities to Medical Staff Executive Committee. Reviews and summarizes monitoring and evaluation activities and maintains current records. Coordinates data retrieval for essential studies and reports. Ensures licensure and accreditation activities are in compliance with established standards and regulations. Obtains and distributes current information of all applicable licensing criteria and accreditation standards.*Familiar with JCAHO, State, and federal regulations/standards regarding environment of care and safety. Develops plans and conducts fire and emergency preparedness drills, including use of Hazard Vulnerability Analysis and community involvement. Maintains plans and policies in compliance with regulations regarding Safety, Life Safety, Security, Equipment Management, Utilities Management, and Emergency Preparedness. (This in no way states or implies that these are the only duties to be performed)Requirements Education:Graduate of an accredited Nursing (RN) or Social Work program or Bachelor’s Degree in Psychology or other related field. Experience:Prefer five (5) years clinical experience with a psychiatric mental health population, Three (3) years experience in a supervisory role.Licensure / Certification: Current RN license by Board of Nurse Examiners for the State of TN., Licensed Mental Health Professionals, LCSW, or LPC preferred.Knowledge:Possesses knowledge of procedures and principles of risk management related to a health care environment. Current knowledge of regulating /accrediting agency guidelines. Basic knowledge of computer skills and statistical analysis desired.