This job is responsible for providing professional support for the Franciscan Health System (FHS) strategic clinical risk management program which is focused on enhancing patient safety and quality of care and mitigating/minimizing financial loss through risk detection, evaluation, prevention, reduction and resolution. An incumbent researches bills/non-billable events relating to hospital-acquired conditions/sentinel events and participates, under the direction of hospital-based Risk Managers, in the investigation of claims and potential claims.
Work also includes: 1) supporting litigation and insurance processes; 2) researching regulatory requirements and best practices to facilitate implementation of risk strategies/programs to improve patient outcomes and liability risk reduction; 3) analyzing risk-related data to identify trends, differences from benchmark quality data and gaps in standards/processes, and 4) monitors department compliance with corrective action plans.
Work requires knowledge of risk, legal and/or patient safety processes and terminology, and of the objectives of the risk management and/or regulatory/safety functions sufficient to carry out most responsibilities independently. An incumbent uses initiative in carrying out the recurrent work, handling problems and deviations in accordance with established procedures, accepted practice and/or requirements. Guidelines for conducting the work are general, requiring the exercise of independent judgment in determining the most efficient and effective way to achieve desired objectives and in recommending alternative options to billing situations requiring interpretation of complex regulations.
ESSENTIAL JOB FUNCTIONS:
Investigates incidents of hospital-acquired conditions, sentinel events and other incidents involving errors or omissions in the delivery of patient care to identify/clarify non-billable events and coordinate the bill-split process.
Reviews pertinent charts/records/reports and researches/identifies/addresses related risks/issues within defined scope of responsibility.
Works collaboratively with clinical managers, business office and other stakeholders to hold charges until reviewed by the appropriate clinical/hospital department
Follows up to ensure timely and appropriate resolution of specific cases
Keeps abreast of current relevant regulations applicable to non-billable events and other documentation clarifying application to specific situations; recommends and implements formal procedures/processes to train stakeholders and facilitate regulatory compliance.
Reviews and analyzes IRIS incident reports to identify opportunities to improve the delivery of safe patient care; develops reports and presentations as directed by Risk Managers.
Prepares and maintains summaries of investigations, recommendations and corrective action plans in an organized and retrievable fashion; assists with follow-up and documentation of implementation of risk reduction strategies.
Identifies gaps in standards/processes with potential to cause adverse patient care/safety outcomes and that increase risk, liability and/or litigation costs to the organization.
Compares FHS results to benchmark data from external quality measurement databases (e.g. CalNOC, etc) to identify variances and gaps; researches and identifies reasons for disparity, documents findings and escalates to management for review and action.
Maintains database of sentinel events; updates department action plans designed to implement procedural changes and remedial actions to facilitate performance improvements and avoid recurrence of adverse events.
Maintains tracking database and follows up with risk manager and/or department to ensure departments are in compliance with the provisions of the approved action plan and meeting established timelines; identifies non-compliant departments and escalates for management attention.
Updates database to reflect completion/conclusion of department action plans.
Researches applicable regulatory requirements and best practices on a regular basis to facilitate the development/implementation of risk strategies/programs to achieve better patient outcomes and liability risk reduction; participates in the implementation, documentation, evaluation and follow-up of risk reduction initiatives/programs/tools; monitors ongoing compliance with loss prevention programs.
Identifies compliance issues and participates in the development of appropriate plans to close the gaps to achieving positive outcomes and minimizing loss exposure and to allow management to respond proactively to the reinforced emphasis on measuring/understanding the quality of care and related safety provided.
Analyzes the impact of current programs/protocols on patient care and safety outcomes; evaluates enterprise data to establish targets and develop action plans to optimize operational performance; understands cause-and-effect relationships within various aspects of programs.
Researches, identifies and validates evidence-based best practices in clinical practice and patient safety to provide guidance to clinical areas in performance improvement activities; researches nature/scope of impact on existing activities and makes appropriate recommendations.
Provides direction to internal operational and support staff on patient safety/risk management requirements/expectations which have an impact on their responsibilities.
Performs continuous data monitoring and reporting; develop deliverables and reports including appropriate dashboards, tables, graphs and maps that clearly and effectively convey the results analyses; assures the integrity of data and reports produced by auditing information submitted to assist in the review of performance improvement initiatives delivered throughout FHS.
Gathers information and completes formal documentation in support of claims, litigation and insurance processes; supports data collection relating to the CHI clinical risk management incentive plan.
Reviews Notice of Occurrences and retrieves/gathers data from patient charts and electronic medical records systems to support Risk Managers in facilitating claims litigation and support.
Researches/gathers all data relevant to the annual determination of insurance premiums; in collaboration with Risk Managers, completes and submits CHI annual insurance survey and incentive plan; works proactively with facilities management and staff to ensure that incentive plan requirements are met.
Collects and organizes performance improvement data as relates to patient safety and produces charts/graphs and other presentation materials for management review.
Performs related duties as required.