Stanislaus Surgical Hospital, LLC

Position Description

Position Title: Director Quality & Risk Management / Department: Quality / Date: August 2016

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

The Director of Quality & Risk Management is responsible for overseeing the hospital’s quality performance and risk management programs to ensure all regulatory requirements and accreditation standard are met.

Reporting Relationships

Reports to the Director of Clinical Services.

Top five principal accountabilities:

Provides clinical expertise to all hospital departments to ensure the highest level of quality and safety for patients.
  • 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.

Organizes and executes all activities related to the Performance Improvement Committee, Quality, Risk Management, and Patient Satisfaction to ensure the highest level of and service to the patients, physicians, staff, and visitors.
  • 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.

Oversees and monitors the medical staff performance evaluation processes, and mandatory quality data reporting according to regulatory requirements and accreditation standards.
  • 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.

Monitors and tracks all components of the hospital Risk Management Program to ensure appropriate assessment of liability and provide support for improvement of processes.
  • 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 leadership ability and exceptional professional behavior while conducting day to day responsibilities at the hospital.
  • 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 staff, management, physicians, patients and family.
  • 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:

It is the responsibility of every employee to integrate security practices in daily work by appropriately using and safeguarding SH IS resources in compliance with SH policies and procedures.

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

Operating expense / Direct # of staff / Indirect # of staff / Avg cases per day

Education/Certification/Licensure:

HS / AA/ AS / BA/ BS / MA/ MS / Other / Cert/ Reg / Licensure
Type
Required / BA/BS in Health Related Field or / BLS at hire.
Desired / Current Valid RN License to practice nursing in CA / Certification in HealthCare Quality (CPHQ)
or Equivalent Ed/Exp

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:

See Attached

Access to Protected Health Information:

This position has access to protected health information. The protected health information this position can access is demographic information, date of service information, insurance/billing information, medical record summary information, and all medical record information. This position requires this patient health information in order to perform the functions outlined as part of this position description.

Sutter Outpatient Services, LLC

Position Title: Director of Quality and Risk Management / Date: December 2015

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):

Activity frequency defined for an 8 hour shift:
R = Rarely = <15 minutes
O = Occasional = <1/3 of shift or <2 hours 30 minutes
F = Frequent = 1/3 to 2/3 of shift or 2 hours 30 minutes to 5 hours 15 minutes
C = Constant = > 2/3 of shift or > 5 hours 15 minutes / * = Essential Function(s): Examples shown under activities are not limited to examples provided. Consider a) Is the function required of other employees in the position? b) If the function were removed, would the position be fundamentally altered? c) Does the employer consider the function essential? REMEMBER: the frequency of an activity is only one measure of whether it is essential. For example, a security guard may rarely need to secure a violent individual; however, if they were medically precluded from performing this function the employee/applicant would be unable to perform an essential function of their job.
Type of Activity / Freq / Type of Activity / Freq / Other Requirements
Sitting – working at computer / C / Simple grasping: writing, filing, holding a phone / C / C.P.R. = Yes / No - YES
Standing – making copies, setting up for meetings / O / Power grasping: opening containers, heavy files, stapling / R / Hearing (may be corrected to normal) = Yes* - YES
Reaching above shoulder height / R / Fine manipulation: data entry, opening envelopes, peeling labels / R / Language/ability to communicate = Yes* - YES
(ability to speak/articulate clearly, ability to express thoughts coherently, ability to follow social norms)
Reaching at or below shoulder – within work area at computer, on phone or reviewing documents / C / Walking: maximum distance = up to 300 ft / C / Visual (may be corrected to 20/40) = YES*, close, depth distance, peripheral & ability to adjust focus - YES
Reaching greater than 18 inches / R / Walking: average distance = 150-175 ft
Surface = Inside/ Outside / C
Inside / Taste/smell = No -NO
Bending over from waist – to access supplies
Bending neck-forward/backward – looking at computer or papers / R
F / Lifting: floor to waist, max wt. = up to 10 lbs / O / Distinguish color = Yes* - YES
Crouching or stooping – to access supplies / R / Floor to waist, average weight = up to 10 lbs / R / Tactile = No - NO
Balancing = stepstool / R / Waist to shoulder, average weight = up to 5 lbs / O / Computer Work Frequency = F* - YES
Climbing = stepstool / R / Overhead, maximum weight = less than 5 lbs / R / Attendance = Yes*
(ability to maintain work schedule and shift and is
capable of regular & predictable attendance) - YES
Kneeling / R / Overhead, average weight = less than 5 lbs / R / Processing = Yes* (ability to focus on a given task, ability to carry out instructions, ability to remember & carry out series of 3-4 instructions, ability to organize & manage time, must have ability to meeting tight deadlines and work under mentally demanding conditions) -YES
Squatting / R / Carrying:
Max weight = Up to 30 lbs Max distance = up to 5 ft / R / Memory = Yes* (recall recent or past events of information, form mental image of things seen and heard) - YES
Crawling / R / Average weight = up to 10 lbs
Average distance = up to 15 ft / R / Perception = Yes* (understands speech, understands accurately perceived images/sound, distinguishes between written words/images) - YES
Repetitive Foot Control: (driving)
a. Right only / R / Driving cars, forklifts or other moving equipment = to meetings, presentations, etc. / R
b. Left only / R / Working near hazardous equipment or machinery = copier/shredder / R
c. Both / R / Walking on uneven ground = inside/outside / R
Pushing/Pulling: files, doors, drawers, etc. / R / Exposure to dust, gas or fumes / R
Cart: force and distance = 5-3 lbs P/P, up to 1,000 ft / R / Exposure to noise = moderate office noise / C
Repetitive use of hands:
a. Right only / C / Exposure to temperature or humidity extreme = inside/outside / R
b. Left only / C / Working at heights = stepstool / R
Cold objects, vibrating tools or lifting awkward object large boxes, presentation materials, display boards, etc. / R

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