Director, Performance Improvement/Risk Management

Position Summary:

Responsible for planning and implementing the performance improvement program and risk management program to meet the needs of the hospital Oversight responsibility for all regulatory body surveys and accreditation bodies. Responsible for risk evaluation, management and corrective action related to risk identification and management.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Develops and coordinates processes to monitor quality of care. Identifies opportunities to improve patient care, treatment and services.
• Effective planning, facilitation and implementation of performance improvement activities to meet the needs of the hospital.
• Knowledge of regulatory standards including, but not limited to State guidelines, CMS regulations and The Joint Commission Standards, and apply knowledge to the operations of the facility.
• Apply knowledgeable of HBIPS and IPFQR standards, including abstraction of data and submission requirements.
• Navigate regulatory websites and accessing updates as needed.
• Works directly with the Joint Commission and CMS vendor.
• An understanding of QualityNet.
• Accurate review of records and data abstraction and timely completion of activities.
• Ability to compile reports, documentation and meeting minutes for committee meetings.
• Servers as the chair of the monthly Performance Improvement Committee meeting.
• Ability to coach and mentor other departments in action planning activities and maintaining accountability for the timely submission of performance improvement activities by all departments.
• Provides support to all departments as required.
• In conjunction with the Safety Officer and other hospital leadership, completion of the annual proactive risk assessment.
• Investigates complaints, incidents and risk events.
• Sound judgement and decision-making skills in formulation of action plans, root cause analysis, and FMEA projects.
• Tracking, quantifying, and ensuring monthly metrics are received and reported from each department, including additional programs
• Gathering, compiling, modeling, validating and analyzing data
• Effectively manage multiple projects
• Validating data acquisition methods
• Compiles reports for committees and administrative team
• Utilizes information obtained via performance improvement activates to seek and act on opportunities to improve patient care processes
• Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.
• Responsible for maintaining current systems to ensure integrity of data obtained during the varying processes performed in the department.
• Ability to perform medical record review for the purpose of identification of real or potential risk and the monitoring of documentation practices.
• Ability to prepare risk identification reports for submission to the legal counsel and the organizational risk carrier
• Ability to prepare risk identification and grievance reports in summary format, for presentation to hospital administration, the medical staff and the Governing Body.
• Summarizes risk management and patient safety data for appropriate evaluation and risk trend analysis
• Oversee staff to ensure the resolution of patient complaints within prescribed time frames.
• Provides oversight of time management and disciplinary actions of reporting staff.
• Responsible for preparing Performance Improvement/Risk Management reports for committee and standing meetings, including EOM (end of month), Governing Board, Medical Executive Meetings, and Safety, as well as other meetings as determined.