- Works with the team to define opportunities to improve processes through rounding identifying trends, offer solutions and works with team to implement change
- Facilitates and participates in committees and meetings that are focused on Quality, Safety, Performance Improvement
- Manages a risk identification process for the organization’s operations, departments, and services. Educates and assists other managers in assessing their areas of responsibility for exposures to loss and unsafe processes and conditions.
- Maintains a risk management information system. Collects, evaluates, and reports on events, incidents, and claims. Performs statistical analysis and trending of events and claims to pinpoint high risk areas for management attention.
- Reviews and analyzes incident reports, rates by severity and conducts all follow-up as identified from review. Completes trending analysis to identify top priority areas for improvement.
- Investigates all serious events. Assists with communication and documentation of errors or serious events in accordance with legal requirements and/or accreditation standards.
- Develops and maintains positive working relationships with providers, management, and staff to promote open communication and accurate flow of information.
- 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.
- Chairs the patient safety triage team and serves on other patient care and safety related committees as member, or as needed to communicate findings, recommendations, actions, and results.
- 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.
- Remains knowledgeable about and promotes compliance with professional standards and guidelines. Implements changes to ensure consistency with regulatory requirements.
- Works with general counsel to coordinate the investigation, processing, settlement, and defense of claims and suits against the organization. Notifies insurance carriers of potential and actual claims. Coordinates the release of information in response to subpoenas, court orders, attorney requests, etc.
- Reviews patient complaints which may result in legal action. Works with patient advocate to offer solutions to patient grievances. Works with billing and compliance officer in deciding on appropriateness of billing waivers/write offs.
- Assists departments with the integration of quality, regulatory, infection control and risk management activities
- Supports process of root cause analysis in the event of a sentinel or near miss event. Coordinates review of medical information, debriefs all individuals as identified, performs cause and effect analysis and coordinates expert panel review, root solution and follow-up for all incidents identified
- Supports FMEA analysis when high volume, high risk opportunities as discovered through incident report analysis. Organizes team, creates process maps, creates failure modes analysis, identifies prevention and/or corrective action strategies and implants as identified
- Assists Senior Director with appropriate reporting of risk events to regulatory agencies and insurance carrier
- Understanding and implementation of programs related to national and local patient safety initiatives
- Acts as liaison to statewide and national collaborative for quality and safety initiatives
- Available on beeper/phone at all times during scheduled working hours. Participates in Administrator on Call rotation.
- Performs all other job related duties as requested by the Senior Director of Operations and Quality.
- Accountable for the on-going integration of the System Quality and Safety Plan.
- Abide by all relevant departmental/hospital policies and procedures.
- Maintain the confidentiality and security of all hospital related, medical staff related and patient related data and information.
- Timely and complete review and investigation of all incidents and grievances reported into the department.
- Under the general supervision of the Senior Director of Operations and Quality as well as the Vice President of Medical Affairs with latitude for independent initiative and judgment, the Quality and Safety program.
- Responsible for assisting with the day to day implementation of the system’s approved Quality and Safety.
- Oversees activities of the Patient Advocate and Human Rights Officer to ensure compliance with reporting obligations as defined by regulating bodies.
- Assist in special projects as requested
- Attend department meetings
- Works with Senior Leadership on ad-hoc projects, (house-wide)
Job Relationships
- Collaborates with the following staff, by job category:
Vice President, Medical Affairs
CNO/COO
Patient Care Directors
Physician Leaders
Case Managers
Patient Care Assessment Coordinator
Director, Care Management Systems
Infection Prevention and Control Nurse Manager
- Serves in a consultative role to the following:
Medical Staff Quality Council
Directors of Support Services
Medical Staff Service Committees
- Serves on Hospital committees as directed including but not limited to:
Medical Staff Quality Council
Policy Committee
Patient Safety Triage Team
Patient Care Assessment Committee
Joint Commission Preparedness
Environment of Care Committee
- Supervised and/or reportable to the following, by job category:
Senior Director of Operations and Quality
Vice President, Medical Affairs
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