Director-FT-Days- Risk Management

DHR Health - US:TX:Edinburg - Days

Summary:

FLSA STATUS: Exempt Non-Exempt

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

The Risk Management Director is responsible for the day-to-day coordination of the hospital's Risk Management function. Manages the functions of the department to ensure that risks are identified and managed in order to reduce institutional liability and to promote patient safety. Manages collection of aggregate data from adverse event reports, claims and loss prevention strategies, for identification of corrective and preventive actions. Conducts investigation of sentinel events, root cause analyses and peer review. Develops and conducts continuing education programs for medical, nursing and clinical support staff.

POSITION EDUCATION/ QUALIFICATIONS:

• Bachelor's Degree, required

• Advanced degree (JD, Master's), strongly preferred

• Background in healthcare required, nursing or legal experience preferred

• Excellent customer service skills required

• Computer skills with thorough knowledge of Microsoft Office suite, required

• Excellent written and verbal communication skills required

• Certification in healthcare risk management (e.g. CPHRM) preferred

• Statistics program skills (e.g. R. SPSS, STATA) preferred

• Bilingual – (English/Spanish) preferred

JOB KNOWLEDGE/EXPERIENCE:

• Five (5) years of clinical or other healthcare related experience required

• Experience in working with teams in a complex organization required

• Knowledge of medical malpractice and healthcare law preferred

• Experience in loss control and claims management preferred

• Risk management experience in a healthcare setting preferred

Responsibilities:

POSITION RESPONSIBILITIES:

• Promotes the facility's mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.
• Ensures Risk Management department supports all staff and physicians during and after any events. This includes required on-call responsibility as first call for any hospital incidents to provide guidance to staff and physicians. The director or, on occasion, appointee, should be the first call for any significant incidents. The director is expected to be physically present to guide staff and physicians for any significant event with high potential for litigation.
• Develops, coordinates and administers facility-wide systems for risk identification, investigation, and reduction; maintains a network of informational sources and experts; performs risk surveys and inspects patient care areas for all new programs and devices; reviews and inspects facility routinely and assesses loss potential.
• Participates on committees directed towards promoting patient safety issues including, but not limited to Patient Safety Committee, Peer Review Committee, Quality Assurance and Performance Improvement Committee.
• Maintains risk management statistics and files in compliance with Joint Commission and state and federal agencies; promotes maximum confidentiality by limiting access of such information. Also strives to verify that the following information is accurate, available, and secure: includes medical records, patient billing records, policies and procedures, incident reports, medical examiner's reports (if available), as well as any other data pertinent to a particular claim or incident.
• Maintains, validates, sorts, tracks, and provides loop closure to all incidents reported via formal hospital reporting system (e.g., RLDatix)
• Prepares monthly reports of tracked data for hospital leadership including Chief of Quality and Peer Review Committee Chairperson.
• Collects, evaluates, and distributes relevant data concerning patient's injuries: aggregate data summaries, monthly trend analyses of incidents, claim profiles and provides aggregate analysis of risk data; maintains statistical trending of losses and other risk management data, working closely with Patient Safety Officer.
• Informs directors of service and department heads regarding occurrences, issues, findings, and risk management suggestions; provides feedback to directors at all levels in the effort to eliminate risks; assists clinical chairs and department heads in designing risk management programs within their departments.
• Works with legal counsel to coordinate the investigation, processing, and defense of claims against the facility; records, collects, documents, maintains, and provides to defense attorneys any requested information and documents necessary to prepare testimony in pending litigation.
• Responds to professional liability and facility liability questions posed by physicians, nurses, and other personnel.
• Advises Director of Security on procedures to reduce the frequency and/or minimize the severity of property loss or assets.
• Provides assistance to departments in complying with Joint Commission or other accrediting agencies, regarding risk management related standards.
• Recommends appropriate revisions to new or existing policies and procedures to reduce the frequency of future occurrences; recommends ways to minimize risks through system changes; reviews and revises facility policies as appropriate to maintain adherence to current standards and requirements.
• Prepares and monitors all policies and forms.
• Educates and trains leadership, staff and business associates as to the risk management program, and their respective responsibilities in carrying out the risk management program.
• Coordinates risk and safety management orientation and continuing education programs for providers, management, and staff to enhance awareness of their role in patient safety, risk reduction, and event reporting.
• Acts as liaison to outside agencies such as local, state, federal, or voluntary accrediting agencies. Prepares reports of events as required by law or in accordance with voluntary participation. Coordinates internal surveys and inspections, monitors reports, and coordinates corrective actions or recommended improvements with management and staff.
• Develops and maintains positive working relationships with physicians, clinicians, management, and staff to promote open communication and accurate flow of information.
• Investigates all serious events on hospital grounds. Assists with the communication and documentation of errors or serious events in accordance with legal requirements and/or accreditation standards.
• Directly refers to administration those incidents with claims potential; reports to higher authority any serious event involving actual or potential injury to patients, visitors or employees.
• Assists in processing summons and complaints served on present and previous employees; assists in defendants in completing necessary documents.
• Screens all patient complaints for risk of potential legal action; discusses and offers solutions when possible to resolve with patient and/or family any grievances perceived as potential liability claims, working with Guest Relations leadership.
• Participates in evaluation of claims for settlement; negotiates settlement of small claims within administrative authority; replacement of lost property after evaluating claim.
• Reviews national and local claims data; analyzes prior claims, lawsuits, and complaints against the facility.
• Notifies the liability insurance carrier of all actual and potential claims, including primary and excess carriers as necessary.
• May verify with the Medical Staff Services Coordinator that each independent practitioner provides proof of adequate professional liability insurance at the time of initial credentialing and at reappointment.
• Oversees morbidity and mortality referrals and process to peer review committee.
• Other duties as assigned.

Other information:

LINES OF REPSONSIBILITIES:

(Chain-of-command)

1. Chief of Quality

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

AGE SPECIFIC:

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age.

AMERICANS WITH DISABILITIES ACT: (ADA):

A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.

The following table provides physical requirements that will be associated with, but not limited to, this position:

Light/moderate lifting up to 20 lbs, from the floor to shoulder height.

Yes

Kneeling

Yes

Must be able to assist other employees with lifting more than 20 lbs.

Yes

Walking

Yes

Light/moderate carrying up to 20 lbs.

Yes

Standing/Squatting

Yes

Straight pulling

Yes

Sitting

Yes

Pulling hand over hand

Yes

Pushing

Yes

Repeated bending

Yes

Stooping/Bending

Yes

Reaching above shoulder

Yes

Climbing Stairs

Yes

Simple grasping

Yes

Climbing Ladders

No

Dual simultaneous grasping

Yes

Depth Perceptions needed

Yes

Ability to see

Yes

Identify Colors

Yes

Operating office equipment

Yes

Twisting

Yes

Operating mechanical equipment

Yes

Crawling

No

Ability to read and write

Yes

Ability to Count

Yes

Ability to hear verbal communication without aid

Yes

Operating Personal Vehicle

Yes

Ability to comprehend written/verbal communication

Yes

Other: Ability to deal with stress

Yes

OSHA Category

III

B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

D. Aptitudes: HIGH LOW

Intelligence: General learning ability: The ability to "catch on" or understand instructions and underlying principles. Ability to reason and make judgments. 3

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to "visualize" objects or two or three dimensions, or to think visually of geometric forms. 2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3

Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3

I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.

Employee Signature: ________________________________ Date: ____________________

Transfer/Hire Date Effective: ________________________.