DIR - RISK / QUALITY

UHS•Austin, TX

19h

About The Position

The Director of Risk Management and Performance Improvement (DRM/PI) has broad responsibility to ensure the hospital’s compliance at all times with all Joint Commission, CMS, and state regulatory agencies standards and requirements. The DRM/PI is responsible for staff training and education on the hospital’s performance initiatives and measures including outcomes measurement and reporting. The DRM/PI has broad responsibility to protect the hospital's assets from loss. The DRM/PI is responsible for coordinating the loss control efforts and advising management and administration on all potential sources of loss and for making recommendations to minimize or eliminate exposure. The structure and functions of the Risk Management Program are designed so as to comply with guidelines and standards of TJC, other regulatory agencies, and the UHS T.E.R.M.© Program. The Director of Risk Management and Performance Improvement (DRM/PI) has broad responsibility to ensure the hospital’s compliance at all times with the UHS Code of Conduct and Compliance Program policies.

Requirements

Bachelor’s Degree from an accredited college or university required.
Four (4) years of experience in quality and risk management/improving organizational performance within an acute medical or psychiatric treatment setting.
A strong knowledge of JOINT COMMISSION, state of Texas standards, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.

Nice To Haves

Bachelor’s Degree from accredited college or university in nursing, or related health field is preferred.
Master’s Degree preferred.
Combination of education and experience considered.

Responsibilities

Ensures appropriate and timely reporting of occurrences by maintaining a Healthcare Peer Review Reporting system (Occurrence notification system); enters incidents into the MIDAS Database.
Analyzes and trends data.
Identifies actual and potential risk situations and facilitates the determination of causative factors.
Networks with department directors to implement system changes aimed at optimally reducing or eliminating causative factors.
Interfaces with the Patient Advocate specific to patient complaints and assesses/recommends action, on those, which may be a source of potential litigation.
Refers policies that present particular risk in relation to previously identified problems to Corporate Risk Management.
Ensure the hospital meets Joint Commission, CMS, and state regulatory requirements.
Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of Joint Commission, CMS, TDSHS, OSHA regulations and all other applicable federal, state or local law/regulations governing health-care entities.
Assists CEO in facilitating the processing of summons and complaints served on the hospital and its employees.
Assists the Corporate Risk Management as needed to intervene, document and assist in the investigation of all claims.
Coordinates investigation of claims within the facility.
Conducts/facilitates in-services to educate employees and physicians.
Participates in developing/reviewing policies and procedure.
Operates to maintain and facilitate system ensuring hospital and employee adherence to UHS Compliance Program.
Facilitates, develops, and provides educational programs to insure all employees and medical staff are aware of the Risk Management/PI/Compliance concepts and its relation to their specific duties/job role in identifying and reducing liability exposures.
Plans and presents risk management/performance improvement and compliance information to all new employees at hospital orientation.
Plans, facilitates, presents information and suggests topics on risk management/performance improvement and compliance to Committees or hospital departments as necessary and based upon occurrences or claim patterns.
Provides aggregate analysis of risk and performance improvement data and trend analysis to Committees and departments as necessary.
Directly reports to Administration those incidents with claims potential.
Advises the Medical Director and Medical Executive Committee as needed.
Advises physicians on issues of interest or concern including Informed Consent process; Documentation and communication; Accountability; Response to patient/family complaints; and internal problem solving.