Quality Management Director, Risk Manager

Job Summary:

Quality Management Director: Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff and Governing Body. Facilitates performance improvement activities and CQI activities throughout the hospital. Acts as a resource person to administrative team, department managers and medical staff. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, i.e., the accrediting organization, State Licensing Review, CMS Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the institution.

Risk Manager: Responsible for clinical identification, risk evaluation and coordination of corrective action implementation related to risk issues. Provides intervention and education related to risk management issues to promote safe work practices and quality care and services in an environment that is beneficial to the safety, health and well being of all patients, visitors and hospital staff. Coordinates risk programs with all hospital departments, administration and the legal counsel. Reports real and potential risk situations to the Governing Body, medical staff, administration, hospital departments and committees, as appropriate. Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services.

Develops and coordinates processes to monitor quality of care. Identifies opportunities to improve patient care, treatment and services.

Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the hospital.

Ability to facilitate performance improvement and CQI activities throughout the hospital.

Demonstrates effective organizational skills through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team and Governing Body to facilitate the hospitalwide PI program.

Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.

Demonstrates awareness of the responsibilities of the position and how it interfaces with the rest of the healthcare team. Works closely with all department members as required, is flexible to meet the needs of the department and changes in the workload.

Accurately demonstrates use of database systems to document occurrences, medical staff review functions, committee review and actions. Compiles reports for committees and administrative team.

Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations.

Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.

Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required.

Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.

Actively participates in QM meetings, provides oversight for meeting preparation, gives presentations on performance improvement to committee members. Presents risk management statistics and information. Sits as member of UM Committee.

Demonstrates current clinical knowledge as well as current knowledge of regulations and standards as relating to accrediting organizations, CMS and State Health Departments. Remains current in the appropriate fields encompassed by the departments.

Develops PI plan with RM interface in collaboration with the QM Committee. Prepares quarterly and annual evaluation of PI program and plan, presents this to QM Committee and Governing Body. Develops PI annual work plan, monitors work plan to evaluate time frame compliance.

Reviews and directs submission of monthly, quarterly and annual reports as required.

Responsible for maintaining current systems to ensure integrity of data obtained during the varying processes performed in the department. Submits PI data as required by external regulatory requirements and collaboratives.

Develops, in collaboration with the medical director, clinical care guidelines for both inpatient and outpatient care settings, in addition to, process and system guidelines.

Consults other departments as appropriate to collaborate in patient care, risk management, utilization management and performance improvement activities.

Exercises sound judgment and decision making skills. Demonstrates the ability to formulate quality action plans, perform root cause analysis and recommend alternative courses of action to reduce potential quality and/or risk concerns or to improve existing processes.

Provides education to staff on risk management, utilization management and performance improvement. Ability to plan and organize orientation and inservice training for department staff members, participates in guidance and educational programs.

Knowledge of basic components of risk management, including potentially compensable events, risk investigation, reporting and claims management.

Ability to perform medical record review for the purpose of identification of real or potential risk and the monitoring of documentation practices.

Ability to prepare risk identification reports for submission to the legal counsel and the organizational risk carrier.

Ability to prepare risk identification and grievance reports in summary format, for presentation to hospital administration, the medical staff and the Governing Body.

Refers information gathered from risk identification reporting to the appropriate department manager/administrative staff member and/or hospital mechanism for analysis and corrective action to eliminate or reduce risk. Leads and promotes patient safety.

Leads and mentors others in root cause analysis (RCA), healthcare failure mode and effects analysis (FMEA) and hazard vulnerability analysis (HVA) teams.

Summarizes risk management and patient safety data for appropriate evaluation and risk trend analysis.

Prepares and presents risk management and patient safety report to leadership and the Governing Body.

Advises hospital staff, medical staff and/or committees regarding real or potential liability situations.

Advises clinical staff regarding patient care to ensure patient’s needs are met and hospital policy is followed.

Maintains a good working relationship with the legal counsel, administration, medical staff and all hospital departments.

Interacts professionally with patient/family to increase patient/family satisfaction and/or diffuse potential litigious occurrences related to patient/family perception.

Knowledge of appropriate and current documentation practices related to the risk management and patient safety arena.

Provides education to medical and hospital staff on risk management and patient safety practices including, but not limited to, risk identification reports, quality notification reports, key elements of risk reduction, orientation to legal issues and education regarding proper documentation practices that present potential liability problems.

Assists in development of policies and procedures related to risk management practices.

Coordinates interrogatories and deposition preparation as needed.

Coordinates risk management, performance improvement and patient relations information as needed for administrative activities, credentialing and hospital insurers.

Review, evaluates and recommends action on risk related matters pertaining to patients, visitors, staff, students, physical plant and personal property.