Director of Quality Improvement/Risk Management

Position Summary:
Provide services that meet Hospital administrative, Corporate and external agency Quality Improvement/Total Quality Management needs/requirements in a professional and effective manner.

?Essential Functions:
Coordinate hospital-wide Quality Improvement activities.
Update Quality Improvement Plan annually, based on recommendations of Quality Improvement Committee.
Coordinate hospital and departmental Quality Improvement activities plans, as observed by the Group?Director.
Coordinate all external survey and insurance company on-site inspections of the hospital and coordinate development of Action Plans for correction of deficiencies noted in external survey reports, within agreed upon time frame, as observed by the Group Director.
Identify, collect and analyze Medical Staff quality improvement data.
Coordinate facility-wide Total Quality Management activities
Maintain records of Quality Improvement activities
Maintain standards for area of responsibility in compliance with outside survey groups, such as TJC, State DPH, State DMH, HCFA, etc. Correct reported deficiencies within specified time table, as observed by Group Director.
Conduct a written survey of Department Heads at least annually in order to determine the strengths or weaknesses of services. Present acceptable plan which responds to survey results. Implement plan of corrective action with specified time frames.
Complete assigned projects within specified time frames, as observed by the Group Director.
Attend and participate in assigned meetings
Coordinate TERM program and advise management and administration on all potential sources of loss and make recommendations to minimize or eliminate exposure. The structure and functions of the Risk Management Program are designed to comply with guidelines and standards of UHS and the JC and other regulatory agencies
Ensure appropriate and timely reporting of occurrences by maintaining the hospital Quality Review Reporting System (Incident Reporting system)
Perform risk surveys and inspect patient care areas in concert with hospital's safety program objectives.
Review reports on facility and equipment to assess loss potential.
Network with department managers to implement system changes aimed at?? optimally reducing or eliminating causative factors.

Interface Risk Management data with Quality Improvement activities specific to the provision of patient care and assessment of quality data.
Network with Medical Staff to ensure active involvement and participation in: risk identification risk analysis; risk reduction/loss prevention problem solving and program development designed to benefit the clinical aspects of patient care and safety.
Network with Medical Staff Coordinator re: credentialing and privileging process to assure comprehensive and current information re: professional liability experience, results of peer review activities, changes in medical staff memberships, clinical privileges, licensure, etc.
Interface with Patient Advocate specific to patient complaints and assesses / recommends actions, on those which may be a source of potential litigation.
Direct hospital Patient/Family Complaint program in conjunction with hospital administration, recommend actions to resolve patient and/or family grievances against hospital.
Interfaces/communicates with Assistant Corporate Risk Manager and Corporate Legal Counsel, as appropriate.
Contract Review: with assistance from Assistant Corporate Risk Manager, provides advice on contract language necessary to fulfill insurance and risk management requirements; Evaluate patient care contracts negotiated by the hospital, when requested???? by the CEO, to ensure that insurance and liability losses are adequately addressed and that risk is transferred to other party responsible. Consults with?Corporate Risk Manager, as necessary.
Report to Administration and Assistant Corporate Risk Manager those incidents with claims potential
Report to Assistant Corporate Risk Manager any serious risk event involving actual potential injury to patients and visitors.
Facilitate processing of summons and complaints served on the hospital and its employees.
Coordinate investigation of claims within the facility:
Facilitate, develop and provide educational programs to insure all employees and medical staff are aware of the Risk Management concept and its relation to their specific duties/job role.
Provide aggregate analysis of risk data and trend analysis of to Administration, Assistant Corporate Risk Manager, Performance Improvement Committee, Environment of Care Committee, Executive Committee of the Medical Staff, Board of Advisors and Medical Staff Committees or hospital departments, as necessary.
Coordinate corporate Compliance Program and assure components are implemented such as staff education, audits, and investigation.
Coordinate and monitor HMO performance standards and develop corrective action plans when needed.
Maintain standards for area of responsibility throughout the hospital in compliance with outside survey groups, such as TJC, State Department of Public Health, State Department of Mental Health, etc. Correct reported deficiencies within specified time table.
Plan and develop a defensible budget supported by historical and projected data as evaluated by the Managing Director
Work with Medical Records Manager to develop budget for this area.
Remain knowledgeable and informed of on-going changes and developments in TQM, QI, RM, UR and accrediting and regulatory standards
Collaborates with managers of other departments to promote and support inter-disciplinary culture.?

Educational Requirements:
? Registered Nurse ? 5+ years experience working in Quality Improvement and Risk Management?
Knowledge Skills Requirements:
Risk Identification and Evaluation, Risk Reduction, Claims Management

?Equipment Operated:
Telephone, Copy machine, Computer, Calculator, Facsimile machine, Postage meter, Policies, procedures, plans, and program manuals
Work Environment:
Position is in a well-lighted office environment.
Physical/Mental Requirements:
Must be able to bend and sit, for long periods. Must be able to lift and move stacks of file folders.? Must be able to communicate verbally with other staff.? Must be able to perform computer/word processing operations.

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