Job Description:
Currently, we have a dynamic opportunity for a Director of Risk Management. The Director is responsible for administrative, technical, and coordinating support to and for working collaboratively with the Performance Improvement Council (PIC) in the development, implementation and evaluation of the Performance Improvement Program that meets accreditation and regulatory guidelines.
This individual manages and coordinates the Performance Improvement and Risk Management Programs throughout the organization. In collaboration with the Medical Staff, Patient Care Services, Nursing, Support Services and other departments, the Performance Improvement and Risk Management Director implements performance improvement (PI) and risk management programs through department-specific and organization-wide planning, coordinates reports to the Medical Executive Committee (MEC), PIC, Board of Directors and accreditation/regulatory agencies.
Key Responsibilities:
1.Responsible for coordinating, facilitating and monitoring hospital-wide PI activities/initiatives including inpatient and outpatient Core Measure data abstraction, analysis, and committee reporting.
2. Responsible for coordinating, facilitating, and monitoring patient satisfaction improvement initiatives, including data reporting to hospital committees.
3. Responsible for coordinating, facilitating and monitoring hospital-wide risk management activities/initiatives including data abstraction, analysis, and reporting.
4. Responsible for coordinating and facilitating hospital-wide accreditation and regulatory agency survey preparedness and readiness, which includes staff and physician education.
5. Responsible for conducting a minimum of two failure mode and effects analysis annually and reporting findings to appropriate senior management and PI committees.
6. Responsible for conducting and/or facilitating a minimum of four Root Cause Analysis (RCA) annually and reporting findings to appropriate senior management and PI committees.
7. Responsible for coordinating and facilitating peer review activities as needed.
8. Assures policy and procedure standards comply with local, state, and federal law and regulatory requirements.
9. Maintains effective communication within department, division, and with all relevant colleagues, divisions and Medical Staff.
10. Coordinates/facilitates PI and risk management activities through appropriate committee assignments, defined feedback mechanisms, and periodic evaluation.
11. Provides a climate for PI and risk management goal achievement by educating and encouraging excellence in practice.
12. Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations.
13. Develop and implement department specific policies and procedures.
14. Responsive and flexible when interacting with other managers / directors.
15. Submits accurate and timely status reports to senior management and/or hospital committees.
Qualifications:
1.High level of knowledge related to Joint Commission hospital accreditation standards, California Department of Public Health, and the Centers for Medicare and Medicaid Services standards and regulations.
2. Current RN licensure in the state of California; MSN preferred. Three years recent performance improvement, quality management, and risk management experience in acute care preferred.
3. Professionals that do not have a RN license: Bachelor’s degree in healthcare administration, business administration, public health, biological science; or doctoral degree in medicine; or Certified Professional in Healthcare Quality (CPHQ) certification. Professional must have four or more years recent performance improvement, quality management, and risk management experience in acute care setting.
4. Certified Professional in Healthcare Quality (CPHQ) preferred.
5. Intermediate to advance level Microsoft Excel database and statistical analysis skills required.
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