Quality Improvement, Risk Management, and Infection Control Manager

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

Responsibility for the initiation and direction of the risk management/risk avoidance function for the hospital, VNA, SNF, and new programs as developed.

Develops goals and objectives and establishes and implements policies and procedures for program operation.

Keeps administration informed of program activities, needs, and problems.

Develops a system to measure risk management programs.

Reviews all documents as requested for loss control/loss prevention purposes.

Coordinates the occurrence-incident reporting system in compliance with regulatory agencies and hospital policy.

Investigates and analyses actual and potential risks in the organization.

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.

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.

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.

Responsible for the preparation of a variety of reports, statistics, projects, and studies within areas of own position responsibilities.

Maintains current knowledge of new trends and developments within your areas of responsibilities.

Is responsible for the department’s operational excellence and ensures it delivers quality services in accordance with applicable policies, procedures, and professional standards.

Follows the hospital exposure control plans/bloodborne and airborne pathogens.

Promotes effective working relations and works effectively as part of a department/unit team inter- and intradepartmentally to facilitate the department’s/unit’s ability to meet its goals and objectives.

Performs work of equal skill and responsibility as directed. May also perform work of a higher level in preparation for increased responsibility and may be requested to do work of lesser responsibility when the work-load requires.

Qualifications

Licenses/Certifications Current California RN license, preferred CPQH, preferred

Required Skills, Knowledge, and Abilities• Must be knowledgeable regarding Joint Comission and governmental regulatio • Must have expertise in Joint Comission survey preparation and coordination.• Must have a high level of written, verbal and interpersonal skills.• Proficient in basic computer skills and understanding of various operating system e.g, MS Windows, Outlook, Word, Excel, PowerPoint)

Hospital Description

Greater El Monte Community Hospital