Job Description

Director of Quality and Risk Management

Cancer care is all we do

Hope in healing

Cancer Treatment Centers of America® (CTCA®) takes a unique and integrative approach to cancer care. Our patient-centered care model is founded on a commitment to personalized medicine, tailoring a combination of treatments to the needs of each individual patient. At the same time, we support patients’ quality of life by offering therapies designed to help them manage the side effects of treatment, addressing their physical, spiritual and emotional needs, so they are better able to stay on their treatment regimens and get back to life. At the core of our whole-person approach is what we call the Mother Standard® of care, so named because it requires that we treat our patients, and one another, like we would want our loved ones to be treated. This innovative approach has earned our hospitals a Best Place to Work distinction and numerous accreditations. Each of us has a stake in the successful outcomes of every patient we treat.

Job Description:

Job Summary/Purpose:

Establishes the direction, function and structure for the organization’s quality, patient safety, risk management and accreditation programs. Maintains oversight for the Infection Prevention program.  Works with the Executive Team, Leaders, Medical Staff and other Stakeholders to establish safe and effective practices to ensure high quality of care for patients and to achieve organizational goals and strategic initiatives. 

Job Responsibilities:

  • Create and execute an effective Quality Management/Performance Improvement program:

    • Develop, implement and monitor the CTCA Phoenix Performance Improvement Plan;

    • Complete and annual review of the PI plan and revise the plan as needed to meet organizational goals and regulatory compliance;

    • Develop metrics to drive improvement of care and processes;

    • Oversite of data collection, reporting and submission to regulatory bodies: CMS and TJC;

    • Serves as system administrator for QualityNet or other programs utilized to submit data to regulatory agencies;

    • Collaborates with IT and clinical leaders on Meaningful Use activities;

    • Work with department leaders and the medical staff to identify meaningful metrics to improve processes and care;

    • Serves as the organization’s subject matter expert for quality and performance improvement;

    • Oversees LEAN activities at the organizational level which impact quality, such as Rapid Improvement Events.

    • Provide education throughout CTCA Phoenix on quality management and performance improvement purpose, methods, data collection, analysis and reporting;

    • In collaboration with Administration and Medical Staff leaders, manages the organization’s peer review functions, including OPPE/FPPE;

    • Responsible for the Quality Patient Safety Committee;

    • Participates in all Enterprise-wide Quality Management/Performance Improvement initiatives.

  • Coordinate and execute the Risk Management/Patient Safety program:

    • Develop, implement and monitor the risk management/patient safety plan with annual review and revision to meet organizational goals and regulatory compliance;

    • Oversite for the event reporting system to ensure report capture, tracking, analysis and reporting occurs;

    • Provide education through CTA Phoenix on risk management reduction strategies, patient safety tactics, etc.;

    • Work with the CEO and Enterprise Legal to manage potential and actual litigation events;

    • Serves as the organization’s subject matter expert for risk management and patient safety;

    • Oversees Root Cause Analysis or other activities in response to events;

    • Oversees management of the organization’s Complaint and Grievance process;

    • Collaborate with leaders and the medical staff to respond to Sentinel Events, Medical Disclosures, etc.;

    • Collaborate with Administration regarding reporting of Sentinel Events to appropriate regulatory agencies;

  • Coordinate and execute the Accreditation Readiness program for State, CMS and TJC:

    • Develop, implement and monitor accreditation readiness activities;

    • Implement/change activities to respond to new or revised regulations or standards from the State, CMS or TJC;

    • Lead annual review activities to ensure ongoing compliance with existing regulations and standards;

    • Provide education throughout CTCA Phoenix regarding appropriate accreditation readiness topics to ensure all leaders, medical staff, volunteers, stakeholders, etc. are prepared to respond to on site surveys;

    • Serve as the organization’s Administrator for the TJC website;

    • Serves as coordinator and liaison for on-site State, CMS and TJC surveys.

    • Responsible for collecting, compiling and creating responses to CMS and TJC for on-site survey, complaint investigations, etc.;

    • Leads the organization’s Accreditation Readiness Committee;

    • Participates in all Enterprise-wide Accreditation Readiness initiatives.

  • Has oversight for the organization’s policy and procedure management process including development, revision and annual review of policies and procedures.Participates in Enterprise-wide initiatives involving policies and procedures.

  • Oversees the Infection Prevention Program.

  • Maintains current knowledge and understanding of new or revised regulations, standards or other topics for areas of responsibility.

  • Responsible for leadership of the department:

    • Stakeholders:  position management including interview, hiring/firing, evaluation, coaching, mentoring, training, etc. to maintain an act, engaged workforce
    • Budget:  annual budget recommendations and creation in collaboration with Chief Nursing Officer; management of assigned budget to achieve departmental and organizational goals

Minimum Qualifications:

  • Bachelor of Science in Nursing Degree is required, Master’s in Nursing, Health Care Administration, or related area is preferred.

  • Minimum of three (3) years of recent experience in the same/similar role at a Director level or higher, including management of direct reports is required

  • Experience in applying the Toyota Production System (TPS) in a healthcare or transactional environment is preferred.

  • Registered Nurse in the state of Arizona or be able to obtain licensure prior to employment is required.

  • Certified Professional in Healthcare Quality or Certified Professional Healthcare Risk Management required

  • Certification in Centers for Medicare & Medicaid Services or Joint Commission is preferred

  • LEAN or Six Sigma certification preferred.

We win together

Each CTCA employee is a Stakeholder, driven to make a true difference and help win the fight against cancer. Each day is a challenge, but this unique experience comes with rewards that you may never have thought possible. To ensure each team member brings his or her best self, we offer exceptional support and immersive training to encourage your personal and professional growth. If you’re ready to be part of something bigger and work with a passionate, dynamic group of care professionals, we invite you to join us. 

Visit:  Jobs.cancercenter.com to begin your journey.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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