Overview Develops and implements strategy relating to matters of quality, outcomes and experience, and for identifying and mitigating risks to the patient and/or staff. Creates and manages major elements of the Strategic A3s relating to Right Care • Oversees all activities relating to complying with the requirements for hospital accreditation and licensure. Interfaces directly with JCAHO, the Mississippi Department of Health, and CMS as necessary. • Oversees the hospital’s benchmarking programs. Is the hospital’s point of contact and manages the hospital’s engagement with Leapfrog, Premier, Quest, and Vizient. • Designs programs and oversees the orientation and education of staff in matters of quality, regulatory compliance, patient safety, and patient experience. • Is the primary liaison with the medical staff in matters of quality, regulatory compliance, investigation of claims and actions, and patient experience. Is the hospital’s representative to the Peer Review, and Quality Committees. • Assists the medical staff office in matters relating to credentialing, the delineation of privileges, the medical staff bylaws and rules and regulations, and the disciplinary process. • Is the primary interface with the corporate departments responsible for quality, compliance, and patient safety at the system level. • Participates in community health activities including mortality review, planning for events impacting the health status of the citizenry, and in the adoption and administration of regulations affecting the hospital. • Prepares and oversees the budget for the assigned areas of responsibility. Recommends programs and expenditures that can influence outcomes, experience, and/or the mitigation of risk. • Develops and administers policy relating to quality, compliance, and patient safety. REQNUMBER: 34856