SUN Behavioral Columbus
Director, Performance Improvement/Risk Management
SUN Behavioral Columbus, Columbus, Ohio, United States, 43224
Director, Performance Improvement/Risk Management
Position:
Director, Performance Improvement/Risk Management at SUN Behavioral Columbus. Responsible for planning and implementing the performance improvement program and risk management program to meet the needs of the hospital. Oversight responsibility for all regulatory body surveys and accreditation bodies. Responsible for risk evaluation, management and corrective action related to risk identification and management.
Responsibilities
Develops and coordinates processes to monitor quality of care. Identifies opportunities to improve patient care, treatment and services.
Effective planning, facilitation and implementation of performance improvement activities to meet the needs of the hospital.
Knowledge of regulatory standards including, but not limited to State guidelines, CMS regulations and The Joint Commission Standards, and apply knowledge to the operations of the facility.
Apply knowledge of HBIPS and IPFQR standards, including abstraction of data and submission requirements.
Navigate regulatory websites and access updates as needed.
Work with the Joint Commission and CMS vendor.
Understand QualityNet.
Accurate review of records and data abstraction and timely completion of activities.
Ability to compile reports, documentation and meeting minutes for committee meetings.
Serve as the chair of the monthly Performance Improvement Committee meeting.
Coach and mentor other departments in action planning activities and maintaining accountability for timely submission of performance improvement activities by all departments.
Provide support to all departments as required.
In conjunction with the Safety Officer and other hospital leadership, complete the annual proactive risk assessment.
Investigate complaints, incidents and risk events.
Demonstrate sound judgement and decision-making skills in formulation of action plans, root cause analysis, and FMEA projects.
Track, quantify, and ensure monthly metrics are received and reported from each department, including additional programs.
Gather, compile, model, validate and analyze data.
Effectively manage multiple projects.
Validate data acquisition methods.
Compile reports for committees and the administrative team.
Utilize information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.
Maintain knowledge of current methodology and practices; stay aware of regulatory changes from accrediting bodies.
Maintain current systems to ensure data integrity during department processes.
Perform medical record review for identification of real or potential risk and monitoring of documentation practices.
Prepare risk identification reports for submission to legal counsel and the organizational risk carrier.
Prepare risk identification and grievance reports for presentation to hospital administration, the medical staff and the Governing Body.
Summarize risk management and patient safety data for evaluation and risk trend analysis.
Oversee staff to ensure the resolution of patient complaints within prescribed time frames.
Provide oversight of time management and disciplinary actions of reporting staff.
Prepare Performance Improvement/Risk Management reports for committee and standing meetings, including end of month, Governing Board, Medical Executive Meetings, and Safety, as well as other meetings as determined.
Chair the monthly Performance Improvement Committee meeting, including data collection, preparation and analysis.
Perform other duties as required.
Safety
Strive to create a safe, healing environment for patients and family members.
Follow all safety rules on the job.
Report near misses, as well as errors and accidents promptly.
Correct minor safety hazards.
Communicate with peers and management regarding hazards identified in the workplace.
Attend required safety programs and understand responsibilities related to general, department, and job-specific safety.
Participate in quality projects and support quality initiatives.
Support and maintain a culture of safety and quality.
Teamwork
Work well with others in a spirit of teamwork and cooperation.
Respond willingly to colleagues and serve as an active part of the hospital team.
Build collaborative relationships with patients, families, staff, and physicians.
Ability to retrieve, communicate, and present data and information verbally and in writing as required.
Demonstrate listening skills and the ability to express or exchange ideas verbally and in writing.
Demonstrate adequate skills in all forms of communication.
Adhere to the Standards of Behavior.
Integrity
Strive to always do the right thing for the patient, coworkers, and the hospital.
Adhere to established standards, policies, procedures, protocols, and laws.
Apply the Mission and Values of SUN Behavioral Health to personal practice and commit to service excellence.
Support and demonstrate fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
Complete required trainings within defined time periods, as established by job description, policies, or hospital leadership.
Exemplify professionalism through good attendance and a positive attitude.
Maintain confidentiality of patient and staff information, following HIPAA and other privacy laws.
Ensure proper documentation in all position activities, following federal and state guidelines.
Compassion
Demonstrate accountability for ensuring the highest quality patient care for patients.
Willingness to be accepting of those in need, and to extend a helping hand.
Desire to go above and beyond for others.
Understand and accept cultural diversity and differences.
Education
Required: Bachelor’s degree in nursing or healthcare-related field. CPR and hospital-selected de-escalation technique certification.
Preferred: Master’s degree in nursing or healthcare-related field.
Maintains education and development appropriate for position.
May substitute experience for education.
Experience
Required: One year of experience in the performance improvement, risk management and quality.
Preferred: Previous experience in a behavioral health setting.
May substitute education for experience.
Seniority level
Director
Employment type
Full-time
Job function
Health Care Provider
Industries
Mental Health Care
#J-18808-Ljbffr
Director, Performance Improvement/Risk Management at SUN Behavioral Columbus. Responsible for planning and implementing the performance improvement program and risk management program to meet the needs of the hospital. Oversight responsibility for all regulatory body surveys and accreditation bodies. Responsible for risk evaluation, management and corrective action related to risk identification and management.
Responsibilities
Develops and coordinates processes to monitor quality of care. Identifies opportunities to improve patient care, treatment and services.
Effective planning, facilitation and implementation of performance improvement activities to meet the needs of the hospital.
Knowledge of regulatory standards including, but not limited to State guidelines, CMS regulations and The Joint Commission Standards, and apply knowledge to the operations of the facility.
Apply knowledge of HBIPS and IPFQR standards, including abstraction of data and submission requirements.
Navigate regulatory websites and access updates as needed.
Work with the Joint Commission and CMS vendor.
Understand QualityNet.
Accurate review of records and data abstraction and timely completion of activities.
Ability to compile reports, documentation and meeting minutes for committee meetings.
Serve as the chair of the monthly Performance Improvement Committee meeting.
Coach and mentor other departments in action planning activities and maintaining accountability for timely submission of performance improvement activities by all departments.
Provide support to all departments as required.
In conjunction with the Safety Officer and other hospital leadership, complete the annual proactive risk assessment.
Investigate complaints, incidents and risk events.
Demonstrate sound judgement and decision-making skills in formulation of action plans, root cause analysis, and FMEA projects.
Track, quantify, and ensure monthly metrics are received and reported from each department, including additional programs.
Gather, compile, model, validate and analyze data.
Effectively manage multiple projects.
Validate data acquisition methods.
Compile reports for committees and the administrative team.
Utilize information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.
Maintain knowledge of current methodology and practices; stay aware of regulatory changes from accrediting bodies.
Maintain current systems to ensure data integrity during department processes.
Perform medical record review for identification of real or potential risk and monitoring of documentation practices.
Prepare risk identification reports for submission to legal counsel and the organizational risk carrier.
Prepare risk identification and grievance reports for presentation to hospital administration, the medical staff and the Governing Body.
Summarize risk management and patient safety data for evaluation and risk trend analysis.
Oversee staff to ensure the resolution of patient complaints within prescribed time frames.
Provide oversight of time management and disciplinary actions of reporting staff.
Prepare Performance Improvement/Risk Management reports for committee and standing meetings, including end of month, Governing Board, Medical Executive Meetings, and Safety, as well as other meetings as determined.
Chair the monthly Performance Improvement Committee meeting, including data collection, preparation and analysis.
Perform other duties as required.
Safety
Strive to create a safe, healing environment for patients and family members.
Follow all safety rules on the job.
Report near misses, as well as errors and accidents promptly.
Correct minor safety hazards.
Communicate with peers and management regarding hazards identified in the workplace.
Attend required safety programs and understand responsibilities related to general, department, and job-specific safety.
Participate in quality projects and support quality initiatives.
Support and maintain a culture of safety and quality.
Teamwork
Work well with others in a spirit of teamwork and cooperation.
Respond willingly to colleagues and serve as an active part of the hospital team.
Build collaborative relationships with patients, families, staff, and physicians.
Ability to retrieve, communicate, and present data and information verbally and in writing as required.
Demonstrate listening skills and the ability to express or exchange ideas verbally and in writing.
Demonstrate adequate skills in all forms of communication.
Adhere to the Standards of Behavior.
Integrity
Strive to always do the right thing for the patient, coworkers, and the hospital.
Adhere to established standards, policies, procedures, protocols, and laws.
Apply the Mission and Values of SUN Behavioral Health to personal practice and commit to service excellence.
Support and demonstrate fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
Complete required trainings within defined time periods, as established by job description, policies, or hospital leadership.
Exemplify professionalism through good attendance and a positive attitude.
Maintain confidentiality of patient and staff information, following HIPAA and other privacy laws.
Ensure proper documentation in all position activities, following federal and state guidelines.
Compassion
Demonstrate accountability for ensuring the highest quality patient care for patients.
Willingness to be accepting of those in need, and to extend a helping hand.
Desire to go above and beyond for others.
Understand and accept cultural diversity and differences.
Education
Required: Bachelor’s degree in nursing or healthcare-related field. CPR and hospital-selected de-escalation technique certification.
Preferred: Master’s degree in nursing or healthcare-related field.
Maintains education and development appropriate for position.
May substitute experience for education.
Experience
Required: One year of experience in the performance improvement, risk management and quality.
Preferred: Previous experience in a behavioral health setting.
May substitute education for experience.
Seniority level
Director
Employment type
Full-time
Job function
Health Care Provider
Industries
Mental Health Care
#J-18808-Ljbffr