PD Template Short Version 04-15-08 V3

Stanislaus Surgical Hospital, LLC

Position Description

Position Summary (also used as job posting language for Taleo, as applicable):

Reporting Relationships

Top five principal accountabilities:

• Serves as the hospital resource related to quality, risk management.
• Serves as the hospital resource for applicable policy and procedures; federal and state regulations; accreditation standards.

• Collaborates with next level of management, MSEC, and Governing Board to develop goals and objectives that are specific to the quality and risk program consistent with the mission and goals of the hospital.
• Collaborates with the executive team, managers, and team members to develop and implement strategies for achieving departmental goals and objectives to all aspects of areas of responsibility consistent with the direction of the hospital.
• Develops, supervises, directs, and coordinates all activities related to accreditation, regulatory requirements, quality and safety of all aspects of patient care.
• Assists the CEO and CNO with annual review of pertinent policies, procedures, plans, and forms to remain compliant with regulatory and accreditation requirements.
• Delegate's coordination of department needs when out of the department.

• Participates as requested to provide orientation and in-services for employees in area of responsibility.

• Develops, implements and ensures the effectiveness of departmental policies and procedures, ensuring the policies and procedures meet regulatory and accreditation standards.

• Prepares and conducts all Performance Improvement Committee meetings; maintaining all documentation as required by regulatory requirements and accreditation standards.

• Coordinates completion of patient satisfaction surveys with outsourced vendor to ensure scores and return rate are above hospital benchmarks.
• Develops and implements action plans utilizing PDCA format to address any quality and/or risk issues.
• Oversees/submits all benchmarking data to corporate entity and evaluates hospital compare data to identify any opportunities for improvement.

• Reviews patient satisfaction data and reports to appropriate committees and team members; and develops action plans to improve identified areas of concern.

• Participates and coordinates all activities related to utilization review to identify opportunities to reduce re-admissions.

• Identifies problems; researches and identifies cause(s) and possible resolutions, conducts active follow-up.
• Seeks and adapts new approaches to problems with ability to adapt to new procedures.

• Ensures all medical staff/allied health performance evaluation files are maintained according to meet regulatory requirements and accreditation standards; following hospital Medical Staff Bylaws and Rules and Regulations. .

• Maintains a complete understanding of the Medical Staff Bylaws and Rules and Regulations.
• Oversees and ensures Value Based Purchasing data is completed accurately and timely to minimize reduction in Medicare reimbursement.
• Monitors the completion and tracking of all on-going professional performance evaluations (OPPE) for all credentialed medical staff and allied health as required by hospital policy, regulatory requirements, and accreditation standards.
• Coordinates with physicians the review and documentation of all focus peer review activities health as required by hospital policy, regulatory requirements, and accreditation standards.
• Provides support and expertise to the CEO, CNO and Chief of Staff as necessary related to MEC meetings.
• Interpreting and reporting all mandatory quality data to PIRM and other Committees as necessary.

• Ensures all employees complete employee/patient incident documentation in a thorough and timely manner, as required by hospital.

• Coordinates/submits all mandatory state/accrediting body reporting related to Adverse Events timely to prevent fines.

• Monitors all occurrence reports and evaluates, tracks, and trends and reports to executive leadership and corporate entity as appropriate.
• Collaborates with legal counsel as necessary related to litigation or potential litigation.
• Completes all root cause analysis per policy for all adverse events, patient safety, or sentinel events.

• Demonstrates skills as a team player. As a leader, assures that all aspects of hospital clinical operations are in compliance with Medicare, Medicaid and other regulatory agencies and accreditation standards.

• Demonstrates ability to solve problems timely and constructively; maintains focus on the situation and not personalities-gathers facts before reacting.

• Conducts department/leadership staff meetings at regular intervals for informative and educational purposes to build appropriate communication and effective team environment.

• Facilitates clear communications and efficient operations.
• Delegate’s responsibility to team members, fostering accountability among staff to ensure efficient operations and a high level of service.
• Participates in professional and community organizations/events to represent the facility as appropriate.
• Maintains positive public relations with all customers, physicians, and staff to ensure high morale and satisfaction.
• Develops and maintains a culture of service in the hospital, connecting organizational values to actions.
• Functions as key communicator between the various departments and staff regarding medical staff credentialing, and quality and risk issues.

• Participates in service recovery by taking ownership of the situation and correcting problems. Strives to promote customer satisfaction and follows through to correct problems.
• Models appropriate interaction with physicians and staff to ensure high level of service in all areas of responsibility.
• Responds timely to issues that require a decision.

• Facilitates the development of appropriate working relationships with the Medical Staff Executive Committee, Chief of Staff, and Director of Anesthesia.
• Communicates at all levels of the organization, including regular departmental staff meetings, hospital wide staff meetings, leadership meetings, and communication boards.
• Performs other duties as assigned.

Security:

Quantifiable Dimensions (may be anything that can be quantified – not just dollars driven):

Education/Certification/Licensure:

Experience/Knowledge/Skills:

• Minimum of three years of healthcare quality and/or risk management experience required.
• Knowledge of State, Federal, and Accrediting Body regulations and standards related to healthcare.
• Knowledge of heathcare systems is required. Knowledge of medical terminology, data abstraction principles and guidelines, and statistical process control techniques.
• Ability to relate and work effectively with others
• Demonstrate skills in verbal and written English communications for safe and effective patient care and to meet documentation standards.
• Willingness to participate in goal-setting and educational activities for own professional advancement and that of others.

Physical Requirements:

Access to Protected Health Information:

Sutter Outpatient Services, LLC

Travel required:NoYesIf yes, how often: Occasionally

On-call/standby required:NoYesIf yes, how often: Occasionally

PM or weekend shift required:NoYes If yes, how often:

Physical/Cognitive Requirements (list any physical/cognitive requirements, in addition to completing chart):

Director of Quality and Risk Management 1