Under the supervision of the Quality Director, this position is responsible for supporting the organization-wide Risk and Culture of Safety Improvement journey. Coordinating the facility's risk management activities including but not limited to, managing claims against the facility, interfacing with the facility's legal counsel, administering the risk management program on a day-to-day basis, managing and analyzing risk management data, conducting risk management educational programs, complying with risk management related standards. The role ensures compliance with departmental and administrative policies and procedures; ensures compliance with The Joint Commission, local, state, and federal regulatory agencies; develops/monitors quality improvement programs.
To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.
SafetyFacilitates Department Culture of Safety. Support clinical and applicable non-clinical departments safety programs including investigations and drill downs.
Data AnalysisAnalyzes data, use lead data whenever available.
ReportsCreates audience-specific reports using accurate metrics and appropriate graphs for data being presented. Utilizes Executive Summary for all data presented. Cites data sources in reports to clarify data for readers.
Performance ImprovementSupports organizational Process Improvement Activities in accordance with the Quality, Patient Safety, and PI Plan: Utilizes the scientific methodologies of quality including Five Whys, PDSA, Lean, Root Cause Analysis, and FMEA. Participates with assigned departments in drilldowns on Core Measures and HARMS near misses and actual events. Provides staff support for process improvement activities.
Survey ReadinessParticipates in assigned duty for the Survey Process. Acts within defined role and coordinates with team. Follows survey process for reviewing all forms requested by surveyors, documents all items given to surveyors, if acting as a scribe documents questions asked by surveyors and information given by staff.
TimelinessKeeps all data and reports up to date. Presents complete, accurate reports to appropriate shareholders in a timely manner.
PrioritizationAble to prioritize workload to ensure all quality/safety programs are smoothly operating and not falling behind.
CommunicationWritten and email communication is concise and to the point, using proper grammar and in performed in a manner that improves information sharing and flow.
Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements, and TJC standards and/or standards from other accrediting bodies.
Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position. This position description does not restrict the right of management to assign or reassign duties and responsibilities with and without notice.