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Director - Quality/Risk Management (RN) (Quality Assurance; Full-time)

Company: St. Alexius Hospital Corp
Location: Saint Louis
Posted on: August 18, 2019

Job Description:

Description:
The Director of Quality Improvement is responsible for the oversight of Quality Improvement and Risk Management functions within the Hospital.Quality Improvement: Assures that the facility provides high quality, cost effective medical services to its patients. Implement the goals of the St. Alexius Hospitals Core Measures initiative. Assures the facility is compliant with the regulations of all Federal, State, Local and other regulatory bodies with jurisdiction over its clinical activities. Continuously monitors the outcomes of hospital clinical care activities (in partnership with medical staff); to identify opportunities for improvement and to direct clinical re-engineering activities as required to improve the measured outcomes of patient care activities. Risk Management: Manages the risk management and insurance program for St. Alexius Hospital. Identifies and analyzes loss exposures, measures the financial impact of risks and implements risk management policies. Assumes role of Patient Safety Officer..

Requirements:
JOB DUTIES AND RESPONSIBILITIES:* Denotes the essential job functions according to ADA guidelines.Quality:*1.Serves as a change agent to restructure hospital clinical monitoring activities to reflect the philosophy of the the hospitals initiative change.*2.Serves as the Patient Safety Officer and carries out duties/responsibilities as outlined by the Patient Safety Plan. *3.Assures that data documenting the results of patient care processes are collected on a concurrent basis in electronic format. *4.Organizes process improvement committees on a clinical product line basis and provides staff support services to such committees.*5.Assures that process improvement committees receive data as required to perform their monitoring activities and to formulate their process improvement recommendations. *6.Assures that process improvement teams answer the following questions on a DRG or diagnosis specific basis: a.Are medical staff clinical practices consistent with the best known scientific evidence? b.What are the major complications experienced by our patients? c.Do medical staff practices reflect wide variation in the processes of care? d.If so, which process is associated with the best outcomes? e.What are the DRG specific outcomes experienced by our patients?*7.Assures that process improvement teams develop strategies (based on their monitoring activities) to improve patient care outcomes by assuring that hospital practices reflect the best known science; that best practices are identified and emulated; that variations in clinical care processes are reduced; that reversible causes of patient care complications are identified and reduced or eliminated and that DRG specific patient outcomes are both measured and continuously improved. *8.Prepares reports on a quarterly (or more frequent basis) which document the results of patient care reportable to the MEC and GB.*9.Remains current concerning industry-wide DRG-specific best practices and evaluates such best practices for implementation at facility.*10.Educates Governing Board, medical staff and hospital administrative staff concerning current trends in quality and cost management. 11.Performs other duties as assigned.Risk Management:*1.Coordinates and administers the facility risk management program, overseeing all risk management activities of the facility for the purpose of identifying, investigating, and reducing risk*2.Manages an incident reporting system whereby all incident/occurrence reports are received, reviewed and evaluated*3.Performs risk surveys and inspects patient care areas*4.Receives and investigates reports of product problems to determine appropriate response*5.Reviews and investigates patient complaints or grievances related to patient care and the quality of medical services which may result in legal action*6.Participates in root cause analysis investigations and reporting of sentinel events*7.Directly refers to the corporate risk manager those incidents with claims potential; reports any serious event involving actual or potential injury to patients, visitors, or employees*8.Maintains risk management statistics and files in compliance with the Joint Commission and state and federal agencies; strives to verify that the information is accurate, available, and secure*9.Participates on committees directed related to risk management, patient safety, and/or quality*10.Provides feedback to directors and department heads regarding occurrences, issues, and findings in an effort to eliminate risks and assist in designing risk management programs within their departments*11.Works with legal counsel to coordinate the investigation, processing, and defense of claims against the facility; records, collects, documents, maintains, and provides to defense attorneys any requested information and documents necessary to prepare testimony in pending litigation*12.Works to reduce the frequency and/or minimize the severity of property or asset loss*13.Complies with various codes, laws, rules, and regulations concerning patient care and incident reporting, including those mandated by state and federal agencies; assists the investigation activities of federal, state, and local enforcement authorities, as required*14.Acts as a resource and provides assistance to departments in complying with Joint Commission or other accrediting agencies regarding matters related to patient safety, risk reduction and reporting requirements*15.Acts as liaison to outside agencies such as local, state, federal or voluntary accrediting agencies, takes steps to ascertain that risks are minimized through follow-up and actions on all regulatory and insurance survey report recommendations and deficiencies*16.Disseminates information on claim patterns and risk control, as well as legislative and regulatory changes*17.Recommends appropriate revisions to new or existing policies and procedures to reduce the frequency of future occurrences; recommends ways to minimize risks through system changes; reviews and revises facility policies as appropriate to maintain adherence to current standards and requirements*18.Provides risk management and risk prevention education to facility personnel to enhance their awareness of their role in patient safety, risk reduction and event reporting*19.Prepares reports for facility and corporate management 20.Performs other duties as assigned.JOB REQUISITES:EDUCATION AND TRAINING:BSN or equivalent required; MSN or equivalent preferred.LICENSING/REGISTRATION/CERTIFICATION:Current professional license in the State of MissouriEXPERIENCE:Minimum 5 years experience in quality improvement and risk management preferredSKILLS AND ABILITIES:Demonstrated knowledge of performance improvement, outcomes and quality management Ability to interpret and process data in an analytical manner. Computer operational skills, understanding of database systems. Current understanding of Joint Commission regulations.Must show ability to interpret, process and analyze data. Must have demonstrated computer literacy and understanding of statistics, database and spreadsheet analysis. Must demonstrate understanding of current trends in quality and cost management as well as managed care and capitation. Must be able to work as a "Change Agent" to motivate relevant constituencies to enthusiastically embrace change as required by the Core Measures initiative and other attendant clinical re-engineering initiatives. An individual without requisites stated above may present a written justification explaining the relevance of his/her background for a specific vacant position. Depending on organizational needs and availability of more qualified applicants, an applicant may have some or all requisites revised or waived at the hospitals discretion.PHYSICAL REQUIREMENTS/WORKING CONDITIONS:ESTIMATED PERCENTAGE OF TIME INCUMBENT COULD BE EXPECTED TO CARRY, PUSH, PULL, OR LIFT:0 10 % 11 33% 34 66% 67 100%A. up to 10 lbs 67-100%B. 11 - 24 lbs 0-10%C. 25 - 34 lbs 0-10%D. 35 - 50 lbs 0-10%E. 51 - 74 lbs 0-10%F. 75 - 100 lbs 0-10%ESTIMATED PERCENTAGE OF TIME INCUMBENT COULD BE EXPECTED TO PERFORM THE FOLLOWING ACTIVITIES:0 10 % 11 33% 34 66% 67 100%A. BENDING 0-10%B. CLIMBING 0-10%C. LIFTING 0-10%D. PUSHING/PULLING 0-10%E. REACHING 11-33%F. SITTING 34-66%G. SQUATTING/KNEELING 0-10%H. STANDING 11-33%I. TWISTING 0-10%J. WALKING 34-66%K. KEYBOARDING 67-100%General, sedentary office environment with the ability to perform repetitive tasks to achieve goalswithin specific time lines. Visual acuity for reviewing written documentation and computer work;verbal ability to effectively express ideas and views.MACHINES/EQUIPMENT/TOOLS:PRIMARY:Computer and printerSECONDARY:telephone, scanner, copy machine and faxBLOOD BORNE PATHOGENS CATEGORY:Non-exposurePM19 PI112828959

Keywords: St. Alexius Hospital Corp, St. Louis , Director - Quality/Risk Management (RN) (Quality Assurance; Full-time), Executive , Saint Louis, Missouri

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