This position is responsible for coordinating facility-wide Quality Improvement activities for the purpose of monitoring standards of patient care and to take actions to improve care, and for administering and managing the Facility's Risk Management Program. This includes JCAHO preparation and all regulatory compliance monitoring.
Regulatory Compliance: Understands regulatory requirements of all agencies that review areas of responsibilities. Maintains areas of responsibilities in survey ready status at all times.
Program Development: Plans, develops and implements new programs or policies that promote the organization both internally and externally.
Strategic Planning and Goal Setting: Gathers pertinent information related to departmental and organizational needs. After careful review of business and fiscal trends, chooses a course of action, defines goals and objectives and evaluates results and determines changes as needed.
Performance Management: Accomplishes results through staff by communicating job expectations, planning, and monitoring and appraising staff performance, coaching, counseling and disciplining employees. Uses policies, procedures and standards to enforce expectations and desired productivity.
Communication: Communicates effectively, both verbally and in writing and with all customer groups including physicians, outside referral sources, managers and staff departmentally and interdepartmentally in order to achieve departmental and organizational goals. Accomplishes required written and statistical reports by deadlines and is able to present and use data for required monthly meetings, reports and decision making
Coordinates, implements and evaluates the Facility's internal risk management and performance improvement plans; reviews annually.
Maintains an effective Facility-wide incident reporting system. Investigates and anlayzes the frequency & causes of general categories and specific types of adverse incidents. Receives & confidentially stores all incident reports.
Provides annual and new hire risk management/performance improvement training as well as individualized and small group trainings as needed
Provides confidential, detailed investigative reports in the event of a Level III or Level IV incident. Forwards copies of reports to Chief Executive Officer, Corporate Risk Manager, and Corporate Claims Department. Maintains all documents and evidence items in a safe, secure manner.
Provides quarterly/annual reports to the Facility's Governing Board summarizing incidents, complaints, survey activity, and Facility performance measures.
Participates in daily operations meeting, Pharmacy & Therapeutics Committee, EOC/Safety Committee, Medical Executive Staff, Governing Board (consultative) meetings; Chairs Patient Safety Council and RM/PI Committee. Attends additional meetings as requested by Chief executive Officer.
Maintains knowledge and understanding of The Joint Commission (CAMH, CAMBH) and CMS Standards and strategies for compliance. Acts as Facility liaison during survey process including other applicable state and federal regulatory agencies. Ensures timely response and oversees development and implementation of any required corrective actions. Assigns tasks as necessary to other departmental managers to assist in overall regulatory compliance.
Coordinates and communicates with all Departments related to Facility compliance with the Technical Elements of Risk Management (TERM) Program. Maintains compliance with TERM in his/her areas of responsibility and reports compliance issues appropriately.
Reviews and analyzes root causes, patterns, or trends in data collection and informs applicable Facility management staff; helps to identify and implement corrective action and performance improvement processes.
Provides continuous support in the analysis of performance improvement initiatives and re-establishing requirements which will facilitate continuous improvement. Fosters the development and tracking of performance indicators at the departmental level; encourages a facility-wide team effort in meeting performance improvement goals.