Reporting to the CEO, the Director of Risk Management and Performance Improvement directs and manages an effective organization-wide clinical service delivery system.
Master’s degree in behavioral health/risk discipline, Registered Nurse, or equivalent combination of education and experience. Licensure: (i.e.) -LAPC, LPC, LMSW, LCSW or other behavioral health/risk discipline licensure, preferred.
Employee will participate in General Hospital Orientation and Department / Job Orientation, including competencies for this position. CPR and CPI (Crisis Prevention Intervention) training is required. Will attend hospital safety trainings.
Every year, employees must participate in RiverWoods’ annual staff requirements, including testing for Tuberculosis. Staff members must attend all mandatory in-services and are encouraged to participate in activities that enhance their professional growth and development.
Employees will receive performance appraisals or evaluations after 90 days and then annually on the hospital’s common review.
Essential Job Duties:
- Serve as a key member of the hospital management team, and ensure integration of Risk Management/PI into overall organization operations.
- Develops and implements systems, policies, and procedures for the identification, collection, and analysis of performance measurement data and risk related information.
- Collects and summarizes patient safety data monthly.
- Ensures that Joint Commission HBIPS data is collected and transmitted timely.
- Develops and implements the organization’s risk management/performance improvement program in a manner that fulfills the mission and strategic goals of the organization while complying with state and federal laws and accreditation standards related to safety and risk management.
- Educates and trains the leadership, staff to the risk management/performance improvement programs, and their respective responsibilities in carrying out the risk/performance improvement management program.
- Collects, evaluates, and maintains data concerning risk-related data and performance improvement indicators.
- Assists in processing summonses and claims against the facility by working with corporate office to coordinate the investigation, processing and defense of claims against the organization.
- Actively participates in or facilitates committees related to risk management, safety, and quality improvement.
- Coordinates and facilitates clinical risk management activities to prevent and/or to minimize losses associated with identifying risk, and to minimize and prevent claims of general liability against the hospital.
- Provides direction and coordination for the development and implementation of the performance improvement plan for RiverWoods.
- Interfaces with all department managers at RiverWoods. Responsible for guiding department heads in all performance improvement efforts and risk related issues.
- Monitors Joint Commission standards compliance on an ongoing basis, maintaining a constant state of readiness for survey. Ensures that RiverWoods is in compliance with all regulatory standards (federal, state, and local).
- Annually reviews the Performance Improvement Plan and Risk Management Plan for RiverWoods. Reviews the departmental indicators on a regular basis and makes recommendations as needed to ensure Performance Improvement efforts are effective.
- Responsible for quarterly reporting of hospital compliance data to the Board of Governors.
- Other duties as assigned.
Physical and Mental requirements of Job:
Able to stop, crouch, reach, walk, and stand for sustained periods of time; use extremities to press against something with steady force, as well as pull objects, using extremities to draw, drag, haul, or tug in a sustained motion; able to feel, grasp, and finger objects and lift them from a lower to higher position or horizontally from one position to another; express and exchange ideas via spoken or written work to convey detailed information in an audible and quick manner, able to make fine discriminations in sound and to perceive the nature of sounds with no less than a 40lb loss @Hz, 1,000 Hz and 2,000 Hz, with or without correction; able to substantially move wrist, hands and/or fingers in a repetitive motion.
Must be able to exert up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and occasionally exert up to 50 lbs. of force.
Visual acuity required adequate for preparing and analyzing data and figures, accounting, transcription, characters on computer terminals, reading, and visual inspections necessary.
The worker is not substantially exposed to adverse environmental conditions.
Emotional or Mental Stress:
Must be able to work with several distractions including light conversations. Must be able to deal with aggressive, hostile and irrational behaviors of patients. Must be able to respond immediately in crisis situations concerning patients and/or family members.
The worker may be subjected to environmental conditions that occur inside and outside via routine travel; much work, however, occurs inside under typical hospital conditions.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be misconstrued as an exhaustive list of all responsibilities, duties and skills of personnel so classified.