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Mission Community Hospital · 1 day ago

Risk Manger

Los Angeles, CA

Part-time

Onsite

Mid, Senior Level

2+ years exp

Mission Community Hospital is seeking a Performance Improvement/Risk Manager to oversee the development and implementation of performance improvement programs. The role involves coordinating risk management activities, ensuring compliance with accreditation standards, and facilitating staff training to enhance patient care quality.

Health CareNon ProfitWellness

Responsibilities

MUST have an active RN license

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

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, assists with implementation of 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, DHS and CMS regulations; coordinates compliance and survey activities

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

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

Participates in marketing activities of the Hospital 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

Responsible for coordinating, facilitating and monitoring hospital-wide PI activities/initiatives including inpatient and outpatient Core Measure data abstraction, analysis and reporting; and patient satisfaction improvement initiatives

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

Responsible for conducting a minimum of one 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 two 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

Assist with developing and implementing policies and procedures that support the provision of services

Is responsible and flexible in interactions with other managers / directors

Submits accurate and timely status reports to senior management and/or hospital committees as required

Provides CQI, Improving Organizational Performance 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 performance improvement education for personnel on the FOCUS-PDCA methodology and performance improvement tools at least annually

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 compliance and performance improvement activities

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 ORYX indicators, FEMA, patient safety initiatives, clinical pathways, restraint management, code blue effectiveness / outcomes, staffing effectiveness, DHS corrective actions plans

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 put in place 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 initiation 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 DRG-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, DHS and CMS surveys in collaboration with the Performance Improvement and Operations Committees

Schedules meetings, documents minutes, performs case review in concert with the demands of the medical staff, analyzes and aggregates data and prepare reports for the medical staff

Facilitates/assists with the evaluation of the seven safety plans and revision of the plans for the next year

Demonstrates willingness & ability to float to areas within area of specialty/cross-training

Performs all other duties as related or assigned

Completes unusual occurrence forms within 24 hours of event, if not completed by department director/manager/supervisor

Completes investigations/assessments thoroughly and timely; corrective action plans are formulated and implemented

Reports, promptly, 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

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

Qualification

RN licenseJoint Commission standardsPerformance ImprovementRisk ManagementCertified Professional in Healthcare QualityMicrosoft OfficeStatistical analysisCustomer serviceCommunication skillsTeam collaboration

Required

MUST have an active RN license

High level of knowledge related to Joint Commission hospital accreditation standards, Department of Health and Human Services and the Centers' for Medicare and Medicaid Services regulations

Professional License in area of specialty in the State of California

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