Director of Risk Management

Qualifications

Bachelor’s degree from an accredited college or university in Nursing, or other Health Care related field.  A minimum of three (3) years related experience; OR an equivalent combination of training, education, and work experience which demonstrates the ability to perform the duties of the position.  Familiarity with Hospital quality measures.    

Strong project management skills managing complex, multifaceted projects resulting in measurable success and program growth.  Superior verbal and written communication skills. Excellent people skills, with experience collaborating with a multi – disciplinary, diverse, and dynamic team.  Organizational analytical skills in dealing with people, problems, issues, and information, mediation, reading and interpretation of medical records.  Proficient in computer skills. 

Job Summary

Under the general direction of the Chief Nursing Officer, the Director of Quality, Performance Improvement, Risk Management, and Infection Control, supervises, monitors and evaluates these programs.  The Director of Quality, Performance Improvement, Risk Management, and Infection Control is also responsible for training and supervising staff within those departments and for consumer and systems advocacy.  This position is responsible for assisting with the planning, development, coordination, and evaluation of facility wide quality assurance initiatives.  This position is responsible for supervising Infection Control and other duties as assigned.

POSITION STANDARDS: 

_____1.           Manages and directs the Department’s administrative and financial functions according to established procedures.

_____2.           Coordinates, supervises and directs activities for assigned areas.

_____3.           Provides direction in the assignment of staff according to qualifications. Delegates to appropriate individuals.

_____4.           Department goals are reviewed annually, revised as necessary and a written evaluation of department goals and outcomes is submitted.

_____5.           Accountable for budget and fiscal operations:

                        a.   Prepares Department(s) annual budget for administrative staff and Board of Directors review                         and approval.

                        b.   Controls expenses per standard unit within budgeted figures.

                        c.   Maintains control of overtime.

                        d.   Reviews responsibility summary, general ledger,  and vendor distribution monthly.

                        e.   Provides a written report analyzing variances and other significant data every month.

_____6.           Maintains cost control in utilization of all resources.

_____7.           Maintains open lines of communications with staff, physicians, patients and families.

a.  Communicates to Supervisors and employees through memos, documented departmental meetings with minutes, and bulletin boards.

                        b.   Conduct regular staff meetings as needed to communicate pertinent information, network and collect feedback.

                        c.   Directs and supports staff members as needed.

                        d.   Meets with orientees on a regular basis to evaluate progress and establish goals.

_____8.           Ensures department(s) meet requirements of JCAHO standards to include area(s) of responsibility and those of staff.

_____9.           Establishes and maintains Departmental policies and procedures with requirements of accreditation and regulatory agencies.

_____10.         Interviews prospective employees and makes recommendation for hiring in coordination with Human Resources.

_____11.         Responsible either personally or through delegation for the orientation of new employees.

_____12.         Makes routine employment decisions and reviews performance of the professional and technical staff.

_____13.         Determine the qualifications and competencies of department personnel who provide services.

_____14.         Completes evaluations by the due date.  Reviews evaluation with employees and establishes measurable goals for the next year.

_____15.         Consults with Director of Human Resources to follow proper management procedures in counseling and terminations ensuring compliance with applicable ADA and EEOC guidelines.

_____16.         Initiates corrective action for excessive absenteeism, tardiness or other disciplinary problems. Conducts counseling sessions on a timely basis and in a private confidential manner, involving only those persons who need to be involved.  Follow established steps and guidelines for counseling, using appropriate forms; forwards copies of completed form to be placed to personnel file.

_____17.         Ensures appropriate availability and utilization of staff.

                        a.   Completes Departments schedules.

                        b.   Ensures scheduling of personnel to provide equal and balanced coverage according to employment policies (i.e., weekend and holiday requirements, PT obligations, vacations, etc.)

                        c.   Using all available resources, maintains appropriate staffing levels.

                        d.   Recommending a sufficient number of qualified and competent persons to provide care or services.

_____18.         Develop, manage, coordinate, and conduct follow-up monitoring of new and improved processes and procedures to ensure understanding, consistency, follow through, and completeness of implementation.

_____19.         Remain current with regulatory requirements for Hospitals.

_____20.         Assesses the hospital’s performance related to Joint Commission readiness, National Patient Safety Goals, and CMS Public reporting and compliance, and general clinical performance data analysis and information needs.

_____ 22.        Works collaboratively with medical staff and leadership in support of physician performance improvement activities.

_____ 23.        Ensures that programs and PI initiatives support the reduction of medical/health care errors and other factors that contribute to unintended adverse outcomes.

_____ 24.       Identification of infectious disease processes

Determining the contributing factor(s) of an outbreak within a facility

Identifying an outbreak within a facility

Coordinating processes, procedures and/or policies to combat identified infectious diseases

_____ 25.       Surveillance and epidemiologic investigation

Collect, analyze, monitors and communicates infection control data

Monitors and measures the extent of infectious diseases

Detect infectious organisms and their patterns

Partnering with appropriate healthcare team to analyze and perform job

_____ 26.        Preventing and controlling the transmission of infectious agents

Communicating infection data to staff and patients

Coordinating and/or facilitating educational programming for infection control and prevention

Implementation of evidence-based processes specific to preventing and controlling infections

_____ 27.        Management and communication

Manage the infection control and prevention program/processes

Supervise the infection control prevention program/processes

_____ 28.      Education and research

Educate patients and/or staff about infection control and prevention circumstances

Develop educational programming in infection control and prevention

_____ 29.        Environment of Care

Infection Control serves as consultant in construction and renovation, environmental services, emergency management and more

_____ 30.        Cleaning, sterilization, disinfection and asepsis

Evaluation of disinfection and sterilization processes

Collaboration or consultation with central sterile reprocessing department

DEPARTMENTAL OR UNIT SPECIFIC:

_____1.           Consistently demonstrates a willingness to assist co-workers in the completion of daily tasks or special projects to support the Department's efficiency.

_____2.           Demonstrates a commitment to maintain a positive and effective working relationship with other Hospital departments.

_____3.           Keeps work area organized and clean.

_____4.           Always responds to the Supervisor's request for information and assistance in a timely manner.

_____5.           Inspires confidence from co-workers and others by performing and communicating in a highly professional manner at all times.

_____6.           Demonstrates good verbal and written communication skills. Documents and reports clearly and concisely.

_____7.           Demonstrates the ability to remain friendly and cooperative under all working conditions.

_____8.           Demonstrates movement toward attaining a Hospital Accreditation Professional certification within 2 years.

_____ 9.          Attends and participates on hospital committees.

_____ 10.        Design data collection methods to ensure accurate and complete information gathering. Report required statistics as needed.

_____11.         Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the hospital.

_____12.         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.

_____13.         Assists nursing management in the identification of potential quality of care issues.

_____14.         Participates in department Quality Improvement Plan.

_____15.         Participates in risk management and safety activities.

_____16.         Provides support and assistance to medical staff officers, committee chairpersons and Governing Body as required.

_____17.         Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.

_____18.         Ability to facilitate performance improvement and CQI activities throughout the hospital.

_____19.         Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.

_____20.         Communicates appropriately and clearly to physicians, staff Chief Nursing Officer and administrative team.

_____21.         Accurately demonstrates use of systems to document occurrences, medical staff review functions, committee review and actions. Compiles reports for committees and administrative team.

_____22.         Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations.

_____23.         Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.