Duke University Health System (DUHS) Job Descriptions

DIR, QUALITY, RISK & ACCRED DHLN

Job Title: DIR, QUALITY, RISK & ACCRED DHLN
Job Code: 5681
FLSA: E
Job Level: I2
Revised Date: 05/01/2025
Supervisory Responsibility: Yes

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General Description of the Job Class

Provides strategic direction and oversight of all efforts to improve patient safety, clinical quality, and ensure regulatory readiness. Provides oversight of the process of reporting and analyzing safety events (including safety event reports and sentinel/ & 'never' events) and the development and implementation of an annual patient safety plan. Will collaborate with Medical Staff, Risk Management, Compliance and other Duke Health leadership to evaluate, develop and implement policy and programs to prevent and/or minimize risk, and monitor, analyze and report on patient safety events. Reviews and provides direction on required public reporting including but not limited to CMS, Leapfrog, and others as well as identifies improvement opportunities from performance. Prepares and delivers reports to system governance on the overall program including performance in relevant safety, clinical quality, and regulatory outcomes. Performs other duties assigned by the Chief Medical Officer or the Hospital President. Oversees Quality Improvement, Patient Safety, Accreditation, Risk Management, Infection Prevention and Guest Services for Duke Health Lake Norman. Coordinates education and consultations to the CEO, Board of Directors, medical staff, and department heads and hospital staff. Leads the hospital accreditation survey process. Assures hospital compliance with regulations and standards using regular surveys and centralized tracking.

Duties and Responsibilities of this Level

This role focuses on managing quality, accreditation, risk management, infection prevention and patient relations 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. Oversee all aspects of the organization's Culture of Safety plan including sentinel event reporting, RCA's, system review and other investigation processes.

Lead the design, implementation, and monitoring of hospital-wide quality initiatives aligned with national, state, and local standards.

Develop and oversee quality improvement programs that focus on reducing clinical errors, improving patient outcomes, and ensuring compliance with accreditation standards (e.g., CIHQ, CMS, etc.).

Applies clinical knowledge in formal and informal consultation with individual staff and clinicians, managers, committees/teams and Risk Management to identify and address clinical quality and safety concerns. Chairs the Quality Committee meeting including the coordination of agendas and minute

This position is responsible for identifying trends, prioritizing and recommending improvements for all hospital departments. Apply advanced skills in change management to maintain and promote a harmonious work environment across departments to ensure alignment on clinical quality and safety projects.

In collaboration with Risk Management, coordinates the management of clinical adverse event investigations (to include RCA), risk assessments and follow up on corrective actions as required by regulators, hospital policy or at the request of senior management using best practice, industry standard methodologies.

The leader 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.

Also provides oversight for the Patient Relations department, including review of potential risk concerns, and assistance as needed with other related activities. Monitor and report on quality metrics, patient experience data, and process improvement initiatives, integrating the "voice of our customers" into decision-making.

In conjunction with the senior administrative leadership, develops actionable quality metrics and design data collection methodologies.

Provides oversight and direction on publicly reported performance including CMS, Leapfrog, and other relevant programs including performance review and management for improvement

Partners with Nursing, Pharmacy, Supply Chain, and other clinical departments to develop structures and processes which lead to a high reliability institution and forwards the patient safety agenda.

Plans, direct and overseas operations for Quality, Patient Safety, Risk, and Patient Relations Process Improvement and in partnership with physician and nurse leaders

Participate in orientation and the ongoing education and training of hospital staff. Works collaboratively with the Infection Control Program to identify and correct unsafe conditions and work practices.

Required Qualifications at this Level

Education

Master's degree in healthcare or related field is required.

Experience

Minimum of 7 years of experience, with 3 years in a supervisory role.

Degrees, Licensure, and/or Certification

Knowledge, Skills, and Abilities

Methodologies and tools including but not limited to Lean Management principles, Root Causes Analyses (RCA) and Healthcare Failure Effects Modes & Analysis (HFEMA).

Knowledge of the application of the best tool/graph/visual to use for specific data sets and statistical analysis (e.g., pareto charts, fishbone diagrams, process and value stream mapping, etc.)

Knowledge of system process analysis, quality/process improvement techniques, design, and integration, at a level of complexity associated with integrating processes across multiple departments of an organization.

Possess a level of analytical ability to problem-solve, evaluate, plan, and direct process improvement projects and benchmarking activities for all clinical and non-clinical departments.

Knowledge of the regulatory environment, including CMS, Joint Commission, NCQA

Strong leadership skills with operational experience in patient safety, care management and related fields

Outstanding written and verbal communication skills

Outstanding interpersonal skills allowing complex interactions with all staff levels in the healthcare setting

Must be detail oriented and have high standards of accuracy

Ability to function independently and under time constraints

Strong analytical and communication skills

Distinguishing Characteristics of this Level

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The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

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Duke University is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, (including pregnancy and pregnancy related conditions), sexual orientation, or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

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Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.