Director of Quality/Risk Management

15.9% Retirement plan after 1 year of completed service.

Position Summary:

Reporting to the Chief Nurse Executive, this position plans, directs and supervises Hospital Wide and Medical Staff, Quality Management (QM) and Performance Improvement Plan (PIP) activities in accordance with licensing and accreditation agencies.  Plans and facilitates the QM/PI activities for the Medical Staff Departments in collaboration with the Chief of Staff and Department Chairs.  Requires broad knowledge of clinical and administrative requirements and accreditation and licensure standards.  Manages and supervises the activities of the QM Departmental Staff.

Reporting to the Chief Executive Officer, this position coordinates Risk Management activities for Oak Valley Hospital District (OVHD) which include managing claims against the facility, interfacing with defense legal counsel, insurance carriers and CHW Risk Services, administering the risk management program on a day-to-day basis, and complying with the Joint Commission’s risk management-related standards, such as environment of care, all with the objective of controlling and minimizing loss to protect the assets of the facility.

This position requires the full understanding and active participation in fulfilling the Mission of the Organization.  It is expected that the employee will demonstrate behavior consistent with the Core Values.  The employee shall support the Organization’s strategic plan and the goals and direction of the Performance Improvement Plan.

Position Accountabilities:

1.       Oversees the day-to-day operations of the Quality Management Department.  Provides input to the CEO for departmental capital, labor and operating budgets.  Works with CEO to establish both long and short-term goals for the QM Department.  Remains within acceptable variance of departmental operational and productivity budgets.

2.       Plans and coordinates the activities and maintains the documentation for the Quality Council in collaboration with the Medical Staff Chairman.  Is thoroughly knowledgeable about and assures that the PI Program and the Medical Staff QM are in full compliance with accepted professional, regulatory and accrediting standards and requirements.  Required records, reports, statistics, and other documentation are maintained as necessary.  Actively supports Medical Staff QM with reports and action items as requested or needed.  Develops the annual Hospital Wide PI Plan and facilitates its approval through the appropriate committees at the beginning of each calendar year.

3.       Coordinates the monitoring of medical records for Core Measures, surgical indications, medical management of specific diagnosis and/or procedures, tissue review, blood review, pathology, restraint use, pain management, and documentation as identified by the Medical Staff and QRM Committee.

4.       Prepares and presents required QM/PI reports in accordance with the licensing and accreditation standards and the PI Plan for Medical Staff Department meetings, the QRM Committee, Medical Executive Committee (MEC), and the Governing Board.

5.       Coordinates and facilitates, in conjunction with the Medical Staff Chairs and Directors for each department/services, the Medical Staff Peer Review (PR) activities which includes the Medical Staff Departmental/Services PR Activities, the Medical Staff PR Oversight activities and Medical Staff PI committees.

6.       Identifies and refers Medical Staff cases requiring follow-up by Medical Staff Committees concerning clinical aspects of care through monitoring of generic and department specific indicators.

7.       Maintains confidential California Evidence Code No. 1157 protected case review summaries for Medical Staff committees regarding QM/PI issues and activities. 

8.       Prepares individual QM Profile for physician reappointment in collaboration with Medical Staff Office.

9.       Identifies QM educational needs and educates the Medical Staff, Hospital Administration, Department Directors, Clinical Coordinators and Hospital Staff on the principles of QM/PI, aggregate data collection and graphic interpretation and current status of PI activities as appropriate.

10.   Provides specific direction to and acts as a resource and consultant to Medical Staff regarding QM.  Attends committee and Performance Improvement Team (PIT) meetings for support and advice.

11.   Coordinates PI project activities, including special task forces and policy and procedure development, as directed by Administration.

12.   Analyzes data, considers options, develops a plan of action and takes action as needed.  Evaluates response to plan.  Sets short and long-range goals and objectives, managing change.

13.   Oversees process for Hospital Occurrence Reports (HOR) collection.

14.   Demonstrates the ability to organize workload, set priorities, and uses time efficiently to complete work on time and in an organized manner.

15.   Demonstrates a strong commitment to customer service excellence by communicating with tact, diplomacy and sensitivity in all interactions with Medical Staff, Administrative Staff, co-workers/Peers, and Public in a respectful and caring manner.  Demonstrates a positive professional image; performs responsibilities in a professional manner; demonstrates flexibility and utilizes a collaborative approach with co-workers directed toward achieving positive outcomes.

16.   Sets a high personal standard for accuracy and quality of work.  Demonstrates initiative and creativity in assigned work.  Maintains high confidentiality in all areas of job performance.  Performs work in an honest and ethical manner with sensitivity to those affected by decision outcomes.

17.    Demonstrates understanding of age-specific considerations for the adult population.

18.   Works with legal counsel to coordinate the investigation, processing, and defense of claims against the facility; records, collects, documents, maintains, and provides to attorneys any requested information and documents necessary to prepare testimony in pending litigation.

·         Maintains all legal case files and ensures maximum protection from discoverability of all such files.

·         Participates in evaluation of claims for settlement; negotiates settlement of claims within settlement authority; advises patient accounting/finance of appropriate action for unpaid accounts involved in litigation; approves payment for or replacement of lost property after evaluating claim.

·         Reviews patient complaints that may be the source of potential legal action; discusses and offers solutions when possible to resolve with patient and/or family any grievances perceived as potential liability claims.

·         Responds to professional liability and facility liability questions posed by physicians, nurses and other personnel.

·         Provides education as appropriate to management and staff regarding matter related to Risk Management.

·         Prepares plans and documents required for compliance with Risk Management function of OVHD.

20.   Serves as a member of the Environment of Care/Safety Committee.  Coordinates activities of the Committee including annual review, analysis and recommendation of improvements for overall safety and risk reduction.

21.   Primary contact for licensing for formal evaluations and investigations by the State Department of Health Services and other agencies.  Communicates with appropriate parties and maintains files related to same.

22.  All other duties as assigned.

The following are unit-specific accountabilities

Position Qualifications:

Minimum Education:

Bachelor’s Degree in Health Care or Related Field

High school graduate or equivalent required

Minimum Experience/Skills:

Five (5) years’ health care experience with proven abilities in compliance and team management

Working knowledge of the PI Principles and data analysis

Knowledge of regulatory, accreditation and licensing requirements

Ability to present complex and new concepts to large and small groups

Strong analytical and problem solving abilities

Computer/PC literate (word-processing, spreadsheet & graphics)

Ability to work independently

Able to perform basic mathematical calculations

 
Licenses/Certificates/Credentials:

• California Registered Nursing License

   

Physical Demands:

Prolonged, extensive or considerable sitting

Lifts, positions, pushes up to 25 pounds

Minimal reaching, stooping, bending, kneeling, crouching

Manual dexterity and mobility

Ability to move quick

Adequate vocal pitch and volume

Vision Requirements:

Ability to adjust vision sufficiently to perform duties

Working Conditions:
 Subject to irregular hours based on the demands of the job

 Moderate pressure due to multiple calls, inquiries, and time demands

 Subject to varying and unpredictable situations