Risk Management & Quality Manager

The Hospital Authority of Miller County•Colquitt, GA

About The Position

JOB SUMMARY: Under the direction of the Long-Term Care Director (LTCD) and MNH Administrator, the Risk Management and Quality Coordinator is responsible for the implementation and management of quality services to include the facilities departments, as well as responsibility for oversight of any quality initiatives. As Risk Manager, will perform a variety of duties related to managing potential risks and liabilities within the facility and throughout the organization. Will also include creating and implementing policies that improve both patient care and employee safety. Proactively works to prevent situations that can result in losses or liabilities. GENERAL REQUIREMENTS: Performs all job responsibilities in alignment with the mission and vision of the organization. Performs other duties as required and completes all job functions as per departmental policies and procedures. Maintains current knowledge in present areas of responsibility (i.e., self-education, attends ongoing educational programs). Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time. Wears protective clothing and equipment as appropriate. GENERAL SKILLS: Ability to communicate in English, both verbally and in writing. Additional languages preferred. Strong written and verbal skills. Basic Computer Skills WORKING CONDITIONS: General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels. May be exposed to high noise levels and bright lights. May be exposed to limited hazardous substances or body fluids, or infectious organisms. May be required to change from one task to another or different nature without loss of efficiency or composure. Periods of high stress and fluctuating workloads may occur. May be scheduled as needed including overtime. PHYSICAL REQUIRMENTS & DEMANDS: Have near normal hearing: Hear alarms/telephone/normal speaking voice. Have near normal vision: Clarity of vision (both near and far), ability to distinguish colors. Have good manual dexterity. Have good eye-hand foot coordination. Ability to perform repetitive tasks/motion. Continuously within shift (67-100%): Standing, Walking. Frequently within shift (34-66%): Bending/Stooping, Pushing/Pulling, Lift/carry up to 20lbs, Lift/carry greater than 20 lbs. with assistance. Occasionally within shift (1-33%): Sitting, Climbing, Twist at waist, Lift/Carry greater than 50 lbs. with assistance, Reaching above shoulder. MISSION STATEMENT: QUALITY HEALTHCARE: In our continuing effort to enhance the quality of life for the communities we serve, the Hospital Authority of Miller County is committed to the delivery of superior, safe, cost-effective healthcare through the provisions of education prevention, diagnosis and treatment. JOB SPECIFIC COMPETENCIES: QUALITY IMPROVEMENT AND MANAGEMENT FUNCTIONS: Direct the development and implementation of Quality Improvement, including criteria for evaluation programs and process outcomes. Identify and build opportunities for collaboration with other local, State and Federal organizations involved in relevant quality improvement efforts. Oversee processes for review and development of performance standards and indicators. Work with executive leadership, managers and teams to access and ensure compliance with Quality Management Plan. Provide leadership across the organization in interdisciplinary training, development, and performance improvement processes that contribute to high performance services and teams. Develop and implement policies, procedures and objectives as needed to successfully implement the directives of the performance improvement plans. Abstracts and collects data. Establishes data collection mechanisms internally within the department and externally throughout the facility to meet quality data reporting voluntary and mandatory for patient safety and quality initiatives. Serve as liaison to hospital personnel in issues related to quality activities. Evaluate effectiveness of Quality Management Plan and individual departmental quality activities, redirecting those activities as necessary to ensure adherence to the organization’s Quality Plan, applicable accreditation standards, and national benchmarks. Evaluate effectiveness of CQI and departmental quality activities, redirecting those activities as necessary to ensure adherence to the institutional Performance Improvement Plan, applicable accreditation standards, and national benchmarks. Assist in the development of strategic planning for implementation of long and short range objectives as identified through Performance Improvement Plans. Attend Hospital and Medical Staff quality review committee meetings serving as a technical specialist in the area of quality improvement. Participates in all preparations pertaining to quality reviews, surveys, initiatives, and audits conducted by external organizations and agencies. I.E. HIIN measure submissions, CMS Quality Reporting initiatives, MBQIP Grant Reporting, HIDI Reporting, assist with Strive Campaign. Trains staff in continuous quality improvement (CQI) according to the model adopted by the organization. Conducts and/or assists with investigations of quality concerns, patient complaints and risk issues including analysis of results. Accepts other assignments from the Chief Executive Officer (CEO) as required to accomplish departmental goals. Organizes and provides leadership in the event of Sentinel Event Occurrences, assists with root cause analysis, and/or FMEA processes. Facilitates quality reporting with an upward moving process from the departmental level on throughout the management, executive and governing body levels. Participates in annual Employee Education and New Hire Orientation as needed. Hold quarterly QI Committee Meetings; send invites, create agenda, responsible for minutes and follow-up of actionable items. CLINICAL RISK MANAGEMENT FUNCTIONS: Acts as a resource for medical and ancillary staff with risk management issues. Educates medical and ancillary staff as needed concerning the principles of risk management. Works to integrate quality and risk management issues. Prepares policies and procedures for organization regarding loss prevention. Coordinates and/or is informed of all clinical risk management activities throughout the organization to promote a high standard of care and prevent duplication of effort. Reviews patient complaints that may result in legal action. Reviews/reports serious events involving actual or potential injury to patients, staff or visitors. Informs personnel of changes in regulatory requirements. Conducts/supervises gathering risk management statistics for trending and presentation, i.e. all incident reports; transfers-IP, SWB, ER, AMA’s; Mortality; Blood Utilization. Performs departmental risk surveys including policies, procedures, physical environment and equipment. Assists departments in the development and reporting of relevant risk management indicators. Assists the organization in accreditation survey preparation. Acts as a resource to staff in legal issues concerning medical records, patient care, state and federal regulation and other regulatory requirements. Provides for an organizational system of incident reporting. Acts as a resource for legal counsel. Ensures timely response to inquiries from attorneys. Coordinates staff depositions/interviews. Maintains legal files on open cases. Assists with claims purposes analysis on closed cases for trending. Prepares documents and responds to ADR’s, PBJ audits, denied claims, etc. with approval from the Administrator. PROFESSIONAL REQUIREMENTS: Follows Code of Conduct policy. Adheres to dress code; appearance is neat and clean. Completes annual educational requirements. Maintains regulatory requirements. Maintains patient confidentiality at all times. Reports to work on time and as scheduled; completes work within designated time. Wears identification when on duty; uses computerized time clock system correctly. Completes in-services and returns in a timely fashion. Attends annual review and/or skills fair and department in-services, as scheduled. Attempts to end conversations and other interactions in a positive manner; leaves others with a good impression of the Hospital Authority of Miller County and its employees. Complies with all organizational policies regarding ethical business practices. Communicates the mission statement of the organization. GUEST RELATIONS STANDARDS: (All guest relation violations are subject to disciplinary action up to and including termination): Always treat others in a friendly, helpful manner. Refers co-workers to proper sources when unable to provide an answer. Interacts with others in a professional and friendly manner. Takes interest in others and always gives full cooperation to fellow workers. Always maintains an open line of communication with other departments. Thoroughly familiar with the hospital and the services it offers. OTHER: Responsibility to Report: It is the responsibility of every employee of HAMC to comply with federal, state and local laws and regulations, as well as, HAMC Policies and Procedures. Every employee is help accountable to participate in, comply with and report concerns to his or her supervisor or the Compliance Officer if illegal or unethical behavior is suspected. As an employee of HAMC, you have been granted user access to applicable ePHI systems based on your position. This user or role-based access is intended to give you the minimum necessary access to perform your job function(s) only and should be used only as applicable. OTHER DUITIES: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Requirements

Ability to communicate in English, both verbally and in writing
Strong written and verbal skills
Basic Computer Skills
Associate’s required, Bachelor’s Degree preferred
Minimum 5 years of increasingly responsible experience in health care administration, including: program evaluation, planning, or quality improvement
Knowledge of principles and practices of health care policy and administration including trends in health care planning, policy, management, and program evaluation
Knowledge of Federal, State, and local policies and regulations applicable to healthcare delivery systems
Active American Heart Association BLS certification within 30 days of hire

Nice To Haves

Additional languages preferred.
Certification in Healthcare Risk Management preferred.

Responsibilities

Implementation and management of quality services to include the facilities departments
Oversight of any quality initiatives
Managing potential risks and liabilities within the facility and throughout the organization
Creating and implementing policies that improve both patient care and employee safety
Proactively works to prevent situations that can result in losses or liabilities
Direct the development and implementation of Quality Improvement, including criteria for evaluation programs and process outcomes
Identify and build opportunities for collaboration with other local, State and Federal organizations involved in relevant quality improvement efforts
Oversee processes for review and development of performance standards and indicators
Work with executive leadership, managers and teams to access and ensure compliance with Quality Management Plan
Provide leadership across the organization in interdisciplinary training, development, and performance improvement processes that contribute to high performance services and teams
Develop and implement policies, procedures and objectives as needed to successfully implement the directives of the performance improvement plans
Abstracts and collects data
Establishes data collection mechanisms internally within the department and externally throughout the facility to meet quality data reporting voluntary and mandatory for patient safety and quality initiatives
Serve as liaison to hospital personnel in issues related to quality activities
Evaluate effectiveness of Quality Management Plan and individual departmental quality activities, redirecting those activities as necessary to ensure adherence to the organization’s Quality Plan, applicable accreditation standards, and national benchmarks
Evaluate effectiveness of CQI and departmental quality activities, redirecting those activities as necessary to ensure adherence to the institutional Performance Improvement Plan, applicable accreditation standards, and national benchmarks
Assist in the development of strategic planning for implementation of long and short range objectives as identified through Performance Improvement Plans
Attend Hospital and Medical Staff quality review committee meetings serving as a technical specialist in the area of quality improvement
Participates in all preparations pertaining to quality reviews, surveys, initiatives, and audits conducted by external organizations and agencies. I.E. HIIN measure submissions, CMS Quality Reporting initiatives, MBQIP Grant Reporting, HIDI Reporting, assist with Strive Campaign
Trains staff in continuous quality improvement (CQI) according to the model adopted by the organization
Conducts and/or assists with investigations of quality concerns, patient complaints and risk issues including analysis of results
Accepts other assignments from the Chief Executive Officer (CEO) as required to accomplish departmental goals
Organizes and provides leadership in the event of Sentinel Event Occurrences, assists with root cause analysis, and/or FMEA processes
Facilitates quality reporting with an upward moving process from the departmental level on throughout the management, executive and governing body levels
Participates in annual Employee Education and New Hire Orientation as needed
Hold quarterly QI Committee Meetings; send invites, create agenda, responsible for minutes and follow-up of actionable items
Acts as a resource for medical and ancillary staff with risk management issues
Educates medical and ancillary staff as needed concerning the principles of risk management
Works to integrate quality and risk management issues
Prepares policies and procedures for organization regarding loss prevention
Coordinates and/or is informed of all clinical risk management activities throughout the organization to promote a high standard of care and prevent duplication of effort
Reviews patient complaints that may result in legal action
Reviews/reports serious events involving actual or potential injury to patients, staff or visitors
Informs personnel of changes in regulatory requirements
Conducts/supervises gathering risk management statistics for trending and presentation, i.e. all incident reports; transfers-IP, SWB, ER, AMA’s; Mortality; Blood Utilization
Performs departmental risk surveys including policies, procedures, physical environment and equipment
Assists departments in the development and reporting of relevant risk management indicators
Assists the organization in accreditation survey preparation
Acts as a resource to staff in legal issues concerning medical records, patient care, state and federal regulation and other regulatory requirements
Provides for an organizational system of incident reporting
Acts as a resource for legal counsel
Ensures timely response to inquiries from attorneys
Coordinates staff depositions/interviews
Maintains legal files on open cases
Assists with claims purposes analysis on closed cases for trending
Prepares documents and responds to ADR’s, PBJ audits, denied claims, etc. with approval from the Administrator