Director, Performance Improvement and Risk Management

Position Summary

Under the direction of the Chief Nursing Officer/Chief Operating Officer, the Performance Improvement and Risk Management Director is responsible for administrative, technical, and coordinating support to and for working collaboratively with the Performance Improvement Council (PIC) in the development, implementation and evaluation of the Performance Improvement Program that meets accreditation and regulatory guidelines. He/She manages and coordinates the Performance Improvement and Risk Management Programs throughout the organization. In collaboration with the Medical Staff, Patient Care Services, Nursing, Support Services and other departments, the Performance Improvement and Risk Management Director implements performance improvement (PI) and risk management programs through department-specific and organization-wide planning, coordinates reports to the Medical Executive Committee (MEC), PIC, Board of Directors and accreditation/regulatory agencies. Facilitates the training of hospital staff in the use of performance improvement tools, performance initiatives, corrective action plans development and implementation. Maintains current knowledge of Joint Commission accreditation standards, California Department of Health (CDPH), and Centers for Medicare and Medicaid (CMS) regulations. In addition, the Performance Improvement and Risk Management Director is responsible for coordinating hospital regulatory and accreditation survey activities.

This position requires providing administrative standards compliance supervision to departments, which provide care/service to hospitalized patients in a manner that demonstrates an understanding of the functional, and/or developmental age of the individual served.

This position requires the full understanding and active participation in fulfilling the mission of Mission Community Hospital (MCH). It is expected that the Performance Improvement and Risk Management Director demonstrate behavior consistent with the Mission Community Hospital values and shall support its strategic plan, goals, and direction of the Performance Improvement and Risk Management Plans.

Major Responsibilities

SERVICE PERFORMANCE

• Greets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area.
• Asks how the customer may be helped with interest and concern.
• Listens attentively, does not interrupt.
• Accepts ownership and takes action to resolve customer needs and/or concerns.
• Is attentive and responsive to the expectations of physicians, co-workers and direct reports.
• Accepts constructive criticism and modifies actions accordingly.
• Is generous in acknowledging a job well done.

SERVICE PERFORMANCE (cont.)

• Uses words and behaviors that express consideration, concern and respect.
• Facilitates and holds staff accountable for meeting department customer service standards in the performance of duties.
• Utilizes telephone skills effectively as outlined in the Star Service Program.
• Keeps all private information about staff or patients confidential.
• Identifies customers and their service requirements.
• Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.

VALUE ADDED – INCREASES WORTH OF SERVICE TO MISSION COMMUNITY HOSPITAL

• Participates in marketing activities of the Hospital as requested, including but not limited to committees/task forces, speaking engagements, conducting tours, Hospital sponsored health fairs.
• Contributes to marketing materials such as brochures, newsletters, teaching materials.
• Participates in staff recognition activities in ways that reward behaviors reflecting positively on Mission Community Hospital.
• Engages in interdepartmental /multi-department/house-wide process improvement forums/task forces/committees.
• Offers and implements solutions to challenges/problems.
• Assist with development-related activities including fund raising programs & activities.
• Monitors the marketplace and recommends new and creative business opportunities.
• Analyzes targeted existing services and product lines for cost/benefit and develops appropriate strategies to improve growth where applicable.
• Attends/participates in activities that contribute to professional growth and development.

PERFORMANCE IMPROVEMENT and RISK MANAGEMENT ACTIVITIES

• Responsible for coordinating, facilitating and monitoring hospital-wide PI activities/initiatives including inpatient and outpatient Core Measure data abstraction, analysis, and committee reporting.
• Responsible for coordinating, facilitating, and monitoring patient satisfaction improvement initiatives, including data reporting to hospital committees.
• Responsible for coordinating, facilitating and monitoring hospital-wide risk management activities/initiatives including data abstraction, analysis, and reporting.
• Responsible for coordinating and facilitating hospital-wide accreditation and regulatory agency survey preparedness and readiness, which includes staff and physician education.

PERFORMANCE IMPROVEMENT and RISK MANAGEMENT ACTIVITIES (cont.)

• Responsible for conducting a minimum of two failure mode and effects analysis annually and reporting findings to appropriate senior management and PI committees.
• Responsible for conducting and/or facilitating a minimum of four Root Cause Analysis (RCA) annually and reporting findings to appropriate senior management and PI committees.
• Responsible for coordinating and facilitating peer review activities as needed.
• Assures policy and procedure standards comply with local, state, and federal law and regulatory requirements.
• Maintains effective communication within department, division, and with all relevant colleagues, divisions and Medical Staff.
• Coordinates/facilitates PI and risk management activities through appropriate committee assignments, defined feedback mechanisms, and periodic evaluation.
• Provides a climate for PI and risk management goal achievement by educating and encouraging excellence in practice.
• Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations.
• Develop and implement department specific policies and procedures.
• Responsive and flexible when interacting with other managers / directors.
• Submits accurate and timely status reports to senior management and/or hospital committees.
• Provides continuous quality improvement consultative services to all departments including leadership, medical staff, nursing, and other ancillary departments to insure the development and implementation of a quality management process.
• Orients/provides employee training related to performance improvement and FOCUS-PDCA methodology at monthly hospital orientation.
• Ensures that mechanisms are in place for ongoing PI and risk management data collection, analysis and reporting for important processes and outcomes throughout the organization in order to maintain and improve the quality of patient care and services.
• Identifies and reports national/regional benchmarks or outcomes excellence targets that assist in identifying/supporting performance improvement opportunities.
• Identifies trends and displays opportunities for hospital, medical, department/unit care and/or service improvement via aggregation of data, information, and indicators.
• Uses a disciplined process improvement method (the FOCUS-PDCA methodology- identifies the process, barriers to outcomes and corrective action plans) and performance improvement tools.
• Oversees the systematic monitoring and evaluation of patient care and services, as it relates to regulatory and accreditation compliance, and performance improvement activities.

PERFORMANCE IMPROVEMENT and RISK MANAGEMENT ACTIVITIES (cont)

• Assures that process improvement teams and committees 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, including but not limited to Core Measure indicators, FEMA, patient safety initiatives, clinical pathways, restraint management, code blue effectiveness / outcomes, staffing effectiveness, CDPH corrective actions plans.
• Responds to CDPH Statement of Deficiencies and Plan of Corrections within designated time frame (due date).
• Responds to Joint Commission complaints within designated time frame.
• Monitors QualityNet website for quality measure and Value Based Purchasing updates. Responds to QualityNet action items timely.
• Collects, trends, reports, and displays baseline and concurrent outcomes data demonstrating effectiveness of action plans as compared to national/regional benchmarks or outcomes excellence targets.
• Recommends modification(s) to corrective action plans as appropriate
• Insures that activities are implemented to resolve defined problems.
• Coordinates, manages, and keeps accurate records/files for large volume of information that includes data collection; aggregation and display of information; statistics; the dissemination of information to appropriate committees and personnel; reports; corrective action plans status / resolution; follow-up activities.
• Utilizes opportunities to function as both a designer and initiator of controlled change as needed or appropriate to restructure hospital clinical monitoring activities to reflect the vision and mission of MCH as well as current/anticipated trends.
• Remains current concerning industry wide Diagnostic Related Group – specific best practices and evaluates such best practices for implementation.
• Supports and empowers employees to improve quality of care and/or service.
• Possess and maintains a working knowledge of Joint Commission standards, State of California laws and statutes (e.g., Title XXII), CMS regulations, Medical Staff Bylaws, policies and procedures, and community standards.
• Evaluates, monitors, and sustains compliance with accreditation and regulatory bodies.
• Coordinates MCH’s continuous readiness for the Joint Commission, CDPH and CMS surveys in collaboration with the Performance Improvement and Operations Committees.
• Facilitates/assists with the annual evaluation of the seven Environment of Care safety plans and revision of the plans.
• Performs other duties as related or assigned.

COMPLIANCE

• Ensures unusual occurrence forms are completed within 24 hours of event.
• Completes investigations/assessments thoroughly and timely; corrective action plans are formulated and implemented.
• Promptly reports any suspected or potential violations to laws, regulations, procedures, policies and practices, and cooperates with investigations.
• Conducts all transactions in compliance with all corporate and medical center policies, procedures, standards, and practices.
• Facilitates/fosters compliance with all applicable laws, regulations, procedures, policies and practices required by the job, based on the scope of practice of the position.
• Facilitates identification and reporting of occurrences of potential liability to the Hospital.

INFORMATION MANAGEMENT

• Uses information sources appropriately in department/unit operations.
• Uses department specific information systems applications efficiently and effectively.
• Accesses and creates department specific information system application reports.
• Conducts reality and validation assessments of data processed by the department.
• Serves as an effective resource to IS to ensure accurate entry/updating of department specific systems applications.
• Complies with hospital policies, accreditation agency standards and state and federal confidentiality requirements related to management of information, including HIPAA.
• Obtains necessary training prior to initial equipment and software use.
• Uses software at an intermediate to advanced level.

QUALIFICATIONS:

• High level of knowledge related to Joint Commission hospital accreditation standards, California Department of Public Health, and the Centers for Medicare and Medicaid Services standards and regulations.
• Current RN licensure in the state of California; MSN preferred. Three years recent performance improvement, quality management, and risk management experience in acute care preferred.
• Professionals that do not have a RN license: Bachelor’s degree in healthcare administration, business administration, public health, biological science; or doctoral degree in medicine; or Certified Professional in Healthcare Quality (CPHQ) certification. Professional must have four or more years recent performance improvement, quality management, and risk management experience in acute care setting.
• Certified Professional in Healthcare Quality (CPHQ) preferred.
• Excellent English written/verbal communication skills.
• Computer skilled with experience using Microsoft Office software at an intermediate level.
• Intermediate to advance level Microsoft Excel database and statistical analysis skills required.

Physical Demands

• Physical Requirements:

Ability to negotiate physical environment safely.

Ability to completely lift up to 35 pounds.

Ability to lift patients (with assistance from co-workers and/or lifting devices).

• Visual Requirements:

Ability to translate and understand written communications.

Ability to negotiate physical environment safely.

• Hearing Requirements:

Ability to understand and translate auditory communications accurately.

• Working Conditions:

Standard acute care hospital setting. Standard hospital patient care setting.