Director of Quality and Risk
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POST DATE 9/9/2016
END DATE 11/10/2016
Lake City, FL
JOB DESCRIPTIONJob Code: 06210-2070
Responsible for assisting in the overall coordination of the hospital-wide quality assessment, improvement activities, regulatory and accreditation surveys and compliance. Collects and reviews data from internal and external sources to evaluate the quality of patient care practices in collaboration with the medical staff, departmental director and hospital leadership. Responsible for the facility s Risk Management activities including managing claims against the facility, interfacing with defense legal counsel, administering the risk management program on a day-to-day basis, managing and analyzing risk management data, conducting risk management educational programs, and complying with the Joint Commission s Risk Management Standards, all with the objective of controlling and minimizing loss to protect the assets of the facility. Participates in formulating policy or organizational changes.
* Responsible for the collaborative coordination and preparation of regulatory and accrediting body surveys through ongoing communication and education with other leadership members.
* Assists with providing statistical quality data for Medical Staff Committees as requested.
* Monitors qualitative/quantitative indicators per criteria.
* Analysis of data for trends of improvement and/or areas of concern and recommends appropriate actions.
* Maintains mechanism to follow-up on areas of concern.
* Reviews patient records as requested for QI issues.
* Implements new JCAHO changes in PI standards.
* Designs methodology for tracking review of physicians and/or issues as requested by Committee of Department Chair.
* Maintains the physician QI profiles with strict confidentiality. Compiles monthly physician profiles and submits to Medical Staff Office by specified timeframes.
* Coordinates and has oversight of primarily concurrent and retrospective review of selected records for Medical Staff Committees.
* Works cooperatively with Health Information Management Department s procedure in requesting and returning records for retrospective review.
* Maintains quality improvement reports and abstracts of reviews for QI Department and/or the Department Chair as requested.
* Participates in CQI teams as requested, as a team member or as the facilitator.
* Serves as Patient Safety Officer for the facility.
* Ensures organization and department specific compliance with corporate requirements and requirements of all applicable (local, state and federal) agencies.
* Facilitates development of Hospital Risk Management Program and correlates with facility Strategic plan
* Conducts clinical risk assessments and analysis of complex organizational systems within the facility and facilitates development of corrective action plan
* Conducts annual evaluation of the effectiveness of the Risk Management Program and develops/modifies goals as indicated.
* Formulates analysis plan for data management
* Analyzes incidents/occurrences and identifies patterns as evidence for decision-making
* Provides guidance for an evidence based risk management program for the facility
* Determines the appropriate investigative technique and strategies to utilize with various types of potential claims
* Identifies those occurrences that are potentially compensable events, and submits a PCR report to the HCI Claims Management staff via KOALA or fax
* Oversees investigations of incidents that could lead to professional/general liability claims; negotiates settlement of small claims within authority; makes adjustments to bills as needed and approves payment for lost items
* Works with patients/families and visitors where appropriate to resolve outstanding issues within the guidelines approved by HCI claims Department and facility administration
EDUCATION REQUIRED AND/OR PREFERRED:
* Bachelor s degree in appropriate area of specialization required. Appropriate areas include nursing, allied health, health administration, etc.
* Licensed Health Care Risk Manager (LHCRM) strongly preferred
EXPERIENCE REQUIRED OR PREFERRED:
* Minimum 3 years experiences in performing quality or risk management activities in an acute care setting.
Last Edited: 09/07/2016