SUMMARY OF MAJOR FUNCTIONS
Under supervision of the Vice President of Quality, administers functions within the Performance Improvement Department which includes performance improvement, patient safety, regulatory agency activities, and risk management. Collaborates with other members of the healthcare team to achieve Quality goals, identify risk issues and implement corrective actions.
ESSENTIAL FUNCTIONS AND WORK ROLE RESPONSIBILITIES
1.Collection, analysis, documentation and interpretation of clinical data related to performance improvement, and risk management through case analysis and event identification. Works directly with Administration, Department Directors and Medical Staff to identify and address areas requiring change or development. Assists with meeting regulatory and payor compliance.
2.Assists clinical leaders with analysis and corrective action related to event reporting. Utilizes proven patient safety tools and strategies to integrate corrective actions with sustainable measures across the continuum of care as appropriate to increase effectiveness and quality of patient care.
3.Identifies and investigates potential compensable events for timely reports to meet notification requirements. Assists in management of claims including interacting with defense counsel with pending litigation.
4.Develops and implements training programs to promote teamwork, problem solving, accurate and timely collection of relevant data and other quality related topics as needed.
5.Utilizes proven communication techniques to facilitate performance improvement and change. Mobilizes work groups when necessary to improve systems that manage risk, and improve quality and the effectiveness of services provided at Inland Hospital. Communicates risk management, patient safety and quality improvement information to administration, department leadership, medical staff, employees and committees.
6.Supports System wide and hospital wide performance improvement initiates.
7.Maintains own professional growth and development and utilizes this knowledge to serve the needs of the hospital.
8.Complies with Inland Hospital Hand Hygiene Standards.
9.Adheres to Inland Hospital Standards of Behavior.
10. Performs other duties as assigned.
Generally pleasant work environment.
Hearing and vision acuteness constantly required. No long periods of sitting and/or
standing required. Occasional stress and frustration exist.
1.Maintain a safe environment which includes knowing and understanding hospital and departmental policies and procedures.
2.Report and directly address identified environmental hazards when appropriate.
3.Report and directly address violations of patient safety policy and/or protocol when involved or observed.
Minimal exposure to any type of occupational risks. Position does not involve
exposure to blood, body fluids, or tissue.
PROBABILITY AND CONSEQUENCES OF ERRORS
Lack of adherence to healthcare regulation can result in risk exposure to the hospital
and possible negative patient outcomes. Poor performance will be addressed according
to established progressive disciplinary policies and procedures of Inland Hospital and
Maine State Law.
This a non-supervisory position
MINIMUM REQUIREMENTS FOR THE JOB
A registered nurse with previous risk management and/or performance improvement experience preferred. Past successes in a leadership position and positive role modeling preferred.
Some proficiency in medical record reviews. Impeccable attention to detail and commitment to seeing projects through to fruition. Experience in facilitating group thinking and analysis of systems for the purpose of improvement preferred.
Associate Degree or higher required. Process improvement or clinical background required. Registered nurse or Bachelor's Degree preferred.
Demonstrated competence in administrative practice and knowledge and skill in
program planning development.
SPECIAL KNOWLEDGE REQUIRED
Knowledgeable about Federal and State healthcare regulations and current risk management practice including process improvement tools such as Root Cause Analysis, Plan Do Act Check or LEAN a plus. Position requires self-starter who takes initiative and able to manage multiple priorities.
Must be able to effectively research, survey, comprehend, analyze, plan, organize, control and communicate the activities of assigned responsibilities. CPHRM or CPHQ preferred.
Eastern Maine Healthcare Systems