Director or Quality, Risk Management, and Infection Control

4 weeks ago


South El Monte, United States CareerBuilder Full time

Overview
Responsible for the department of Performance Improvement, Risk Management, and Infection Control. Provides legal advice to administrative and medical staff officers and other appropriate individuals associated with the hospital. Plans, implements, directs, evaluates, and documents an integrated, comprehensive, proactive risk management program for all hospital and community based programs, designed to monitor and, when possible, eliminate the risk of injury to patients, visitors, and employees and to protect the hospital's financial resources. Oversight of the planning, implementing and maintaining comprehensive program of infection control and prevention for all hospital employees and others. Responsible for the overall administration and direction of the PI, Risk, and Infection Control Department, including planning, controlling, monitoring, and directing all the services and operations in the areas of Hospital Wide Performance Improvement, Hospital Wide Compliance, and with all the regulatory agency regulations. This position requires the full understanding and active participation in fulfilling the mission and vision of the AHMC Greater El Monte Community Hospital. It is expected that the employee will demonstrate behavior consistent with core values. The employee shall support AHMC Greater El Monte's strategic plan and the goals and direction of the Performance Improvement Plan
Responsibilities
1. Under the direction of the CEO/COO assumes responsibility for the initiation and direction of the risk management/risk avoidance function for the hospital, VNA, SNF, and new programs as developed
2. Develops goals and objectives and establishes and implements policies and procedures for program operation
3. Keeps administration informed of program activities, needs, and problems.
4. Develops a system to measure risk management programs
5. Reviews all documents as requested for loss control/loss prevention purposes.
6. Coordinates the occurrence-incident reporting system in compliance with regulatory agencies and hospital policy.
7. Investigates and analyses actual and potential risks in the organization
8. Coordinates medical malpractice litigation with insurers and outside defense counsel. Ensures the maintenance of an accurate file of claims investigations and legal defense working through and in cooperation with the involved insurer and their attorney. Develops reports on professional and general liability suits.
9. Works with other department managers to respond to the identified need to modify departmental policy or procedures in order to help protect the hospital and its employees from unnecessary exposure to risk.
10. Works with patients, families, and members of hospital staff and the medical staff to act as a resource to help resolve conflict and minimize litigation.
11. Develops and maintains risk management profiles on individual physicians
12. Ensures confidentiality regarding all risk management and related matters.
13. Makes effective recommendations to applicable hospital committees regarding improvements in both the environmental and clinical risk management programs
14. Responsible for the identification of educational needs, the development of various inservice and related educational programs to meet departmental educational objective, and to comply with the educational requirements of the board of registration in medicine.
15. Responsible for the preparation of a variety of reports, statistics, projects, and studies within areas of own position responsibilities
16. Ensures that all departmental files, records and logs are maintained in a neat, orderly, and up-to-date manner for reference and follow-up purposes.
17. Coordinates all medical staff hearings and appeals in compliance with medical staff by-laws.
18. Assists in the resolution of medical-legal and treatment issues
19. Maintains current knowledge of new trends and developments within your areas of responsibilities.
20. Serves as administrative representative on various hospital, corporate, and medical staff committees.
21. In addition to the previously delineated duties, provides legal and risk management services addressing the unique needs of individual programs
22. Is responsible for the department's operational excellence and ensures it delivers quality services in accordance with applicable policies, procedures, and professional standards
23. Manages HR to ensure quality services and promote positive employee relations.
24. Is responsible for the fiscal management of department and ensures proper utilization of the organization's financial resources..
25. Effectively communicates departmental, organizational, and industrial information to staff.
26. Attains all agreed to goals and objectives within specified time frames, as part of the organization's overall mission.
27. Attends all required safety training programs and can describe his or her responsibilities related to general safety, department/service safety, and specific job-related hazards.
28. Follows the hospital exposure control plans/bloodborne and airborne pathogens
29. Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
30. Promotes effective working relations and works effectively as part of a department/unit team interand intradepartmentally to facilitate the department's/unit's ability to meet its goals and objectives.
Qualifications
* Five to seven years of acute care relevant work experience with minimum of four years demonstrated competence in risk management
* One to Three years supervisory experience
* Current California RN license, preferred CPQH, preferred
* Broad knowledge and understanding of medical and allied health services.
* Hospital experience preparing regulatory or compliance documentation for Joint Commission standards, DHS regulatory requirements and other standards of compliance.
* Experience developing contingency plans to deal with organizational emergencies.
* Ability to ensure all aspects of Risk Management are assessed and evaluated
* Excellent oral and written communication skills
* Minimum two (2) years acute care experience managing and reporting of Infection Control and Prevention standards.
* Bachelor's Degree, Master's Degree preferre
Hospital Description
Greater El Monte Community Hosptial

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