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Risk & Saftey Director
role at
PrimeHealth+
3 days ago Be among the first 25 applicants
Job Summary Responsible for the establishment, implementation and oversight of effective compliance and risk management programs to prevent illegal, unethical risk exposure and improper conduct within the organization. This includes elements of risk mitigation, regulatory compliance, patient safety, infection control, patient grievances and patient satisfaction. The Director of Risk Management interacts with all aspects of the organization as appropriate and reports directly to the Chief Executive Officer (CEO) and Board of Directors (BoD). This position collaborates closely with the Director of Quality in data collection, process improvement and implementation. The Director of Risk Management is responsible for assuring clinic policies and procedures are accurate, organized, up to date and consistent with all regulatory requirements. Fostering a culture of patient and family centered care, service quality and safety excellence, while constantly improving patient experience, employee experience and community relations is key to this role.
Essential Functions Risk Management
Establishes, implements and monitors Marillac’s Risk Management (RM) plan in order to mitigate risks—particularly Potentially Compensable Events (PCEs).
Reports to the CEO and Board of Directors on risk management issues, events and associated action plans.
Provides monthly reports to the Board of Directors on patient satisfaction, risk management trends and risk management events.
Identifies areas of potential vulnerability and risk; develops/implements corrective action plans in collaboration with leadership for resolution of problem areas and provides general guidance on how to avoid similar situations in the future.
Gathers facts regarding PCE’s in order to prepare the health center for case presentation. Interfaces with attorneys regarding PCE’s as necessary.
Oversees the process of obtaining and maintaining Federal Tort Claims Act (FTCA) deemed status along with any gap coverage required.
Audits the health center against known laws and regulations as well as patient grievance process for potential PCEs.
Works with the CFO to ensure adequate liability coverage for all aspects of the health center’s business.
Chairs the Risk Management and Safety Sub-Committee, and reports all required information monthly.
Develops and implements a process for tracking and evaluating risk management events.
Coordinates any Root Cause Analysis (RCA) investigations.
Directs risk management efforts to ensure that performance of clinical services meets or exceeds national standards.
Collaborates with Medical, Dental, Behavioral, Operations, IT and Finance leadership to champion risk reduction programs for Marillac staff and patients. Analyses and uses data to improve outcomes of clinical and non clinical services.
In collaboration with the Director of Quality, leads organizational efforts to obtain and retain PCMH recognition.
Establishes and implements metrics (process capability, control charts, measurement quality) for monitoring system/process effectiveness and to enable managers to make sound patient safety decisions.
Educates and trains employees to implement risk reduction activities.
Collaborates in the development of short and long-range goals for risk reduction and safety performance for incorporation into strategic planning.
Develops, modifies/updates plans and implements policies and procedures to support clinical services. Manages and monitors the distribution, compliance, and regular review of policies.
Infection Control
Assures compliance with testing and vaccination requirements for all Marillac and contracted staff.
Coordinates and oversees MarilacHealth’s procedure for blood and body fluid exposure.
Implements processes for minimizing transmission of infectious disease within all facilities.
In conjunction with the CMO coordinates MarillacHealth’s response to endemic or epidemic infectious disease events.
Advises clinical personnel on emerging infectious diseases relevant to the region.
Develops and assures compliance with employee hand hygiene protocols.
Patient Safety
Plans and implements patient safety policies and activities developed by the health center in support of National Patient Safety Goals.
Exercises oversight and collaboration with key staff to ensure the effective integration of the Patient Safety Program functions by the organization.
Collaborates with senior leadership and managers throughout the organization to ensure the health center participates in a “Just Culture” of safety. Develops staff surveys to assess culture and willingness to report unsafe practices.
Leads the response to incident reports to addresses patient safety issues and leads event analysis and development of corrective action plans. This includes initiation of Root Cause Analysis when indicated.
Collects, analyzes, and reports patient safety data to the Quality and Safety Board Subcommittee.
Patient Grievances And Patient Satisfaction
Initiates, monitors, and reports findings from patient satisfaction surveys.
Identifies and implements efforts to improve patient satisfaction scores.
Collects and evaluates patient grievances, identifying and reporting patterns.
In conjunction with appropriate management and director staff investigates all patient grievances.
Collaborate with responsible leadership in responding to all grievances.
Collaborates with operational leadership regarding patient grievances, reports grievances and action plans to subcommittee facilitates process change to address recommend improvements.
Provides the Board of Directors with a monthly summary of patient grievances and outcomes as well as summary reports of patient satisfaction data and improvement efforts.
Compliance
Develops, modifies/updates plans and implements policies and procedures to support clinical services. Manages the storage, organization and distribution of clinic policies and procedures.
Ensure bi-annual review of all clinic policies and procedures in conjunction with the policy owner.
Works collaboratively with senior leaders and CEO to ensure compliance with federal, state, and local regulatory requirements.
Manages and implements programs, policies, and practices to ensure that all departments comply with applicable law, regulations, and standards of any accrediting bodies.
Reviews policies and procedures of the clinic to determine deficiencies and ensure compliance with federal, state, and county agencies as well as active grants and regulations from accrediting agencies.
Documents laws and regulations that might affect the organization's policies and procedures.
Collaborates with other departments to direct compliance issues to appropriate personnel for investigation and resolution. Consults with attorney as needed to resolve difficult legal compliance issues.
Responds and leads investigations into violations of rules, regulations, policies, procedures, or standards of conduct by evaluating or recommending the initiation of investigation (e.g., RCA). Reports all such issues to appropriate senior leadership and CEO.
Acts as independent review and evaluation body to ensure compliance with applicable regulations and reports regularly to CEO and Board of Directors.
Accreditation
Participates in internal (e.g., Infection Control, Environment of Care) and external audits (e.g., RMHP, HRSA, CDPHE). This includes preparation for and participation in any site visits necessary to obtain or maintain designations and certifications.
Leads compliance audits against laws, policies and regulations and develops action plans with health center’s subject matter experts and leadership. Re-evaluates compliance throughout the year.
Prepares the health center for state and federal audits from planning phase thru exit conference, preparation of action plans and rebuttals.
Other Duties And Responsibilities
As a leader of the organization, be alert to and ensure that the best interests of the organization are maintained.
Perform other duties and responsibilities as required.
Competencies
Knowledge of the principles and practices of risk management, compliance, infection control and patient safety in an organization as well as in the clinical setting. Ability to evaluate and make recommendations for improvement.
Knowledge of primary care operations and Patient Centered Medical Home.
Knowledge of risk management concepts and practices.
Knowledge of applicable laws and regulations within the health care industry.
Knowledge on infectious disease control standards.
Knowledge of applicable computer systems, programs, and applications.
Ability to research, analyze, interpret complex data, and present comprehensive reports.
Skill in exercising a high degree of initiative, judgment, and discretion.
Ability to communicate clearly and effectively orally and in writing.
Required Education/Experience
Bachelor’s degree
Minimum of two years of relevant experience.
Preferred Education/ Experience
Master’s degree in a health care related field.
Three years of clinical experience in nursing or similar clinical experience.
Certified Professional in Healthcare Risk management (CPHRM) or equivalent.
Experience with risk management in governmental accredited institutions.
Experience working in a Federally Qualified Health Center or Look Alike.
Additional Eligibility
Tdap (up to date booster)
Measles, Mumps and Rubella
Varicella (or proof of immunity)
Hepatitis B
Seasonal influenza vaccine
TB Screening also required.
Seniority Level Director
Employment Type Full-time
Job Function Management and Manufacturing
Hospitals and Health Care
#J-18808-Ljbffr
Risk & Saftey Director
role at
PrimeHealth+
3 days ago Be among the first 25 applicants
Job Summary Responsible for the establishment, implementation and oversight of effective compliance and risk management programs to prevent illegal, unethical risk exposure and improper conduct within the organization. This includes elements of risk mitigation, regulatory compliance, patient safety, infection control, patient grievances and patient satisfaction. The Director of Risk Management interacts with all aspects of the organization as appropriate and reports directly to the Chief Executive Officer (CEO) and Board of Directors (BoD). This position collaborates closely with the Director of Quality in data collection, process improvement and implementation. The Director of Risk Management is responsible for assuring clinic policies and procedures are accurate, organized, up to date and consistent with all regulatory requirements. Fostering a culture of patient and family centered care, service quality and safety excellence, while constantly improving patient experience, employee experience and community relations is key to this role.
Essential Functions Risk Management
Establishes, implements and monitors Marillac’s Risk Management (RM) plan in order to mitigate risks—particularly Potentially Compensable Events (PCEs).
Reports to the CEO and Board of Directors on risk management issues, events and associated action plans.
Provides monthly reports to the Board of Directors on patient satisfaction, risk management trends and risk management events.
Identifies areas of potential vulnerability and risk; develops/implements corrective action plans in collaboration with leadership for resolution of problem areas and provides general guidance on how to avoid similar situations in the future.
Gathers facts regarding PCE’s in order to prepare the health center for case presentation. Interfaces with attorneys regarding PCE’s as necessary.
Oversees the process of obtaining and maintaining Federal Tort Claims Act (FTCA) deemed status along with any gap coverage required.
Audits the health center against known laws and regulations as well as patient grievance process for potential PCEs.
Works with the CFO to ensure adequate liability coverage for all aspects of the health center’s business.
Chairs the Risk Management and Safety Sub-Committee, and reports all required information monthly.
Develops and implements a process for tracking and evaluating risk management events.
Coordinates any Root Cause Analysis (RCA) investigations.
Directs risk management efforts to ensure that performance of clinical services meets or exceeds national standards.
Collaborates with Medical, Dental, Behavioral, Operations, IT and Finance leadership to champion risk reduction programs for Marillac staff and patients. Analyses and uses data to improve outcomes of clinical and non clinical services.
In collaboration with the Director of Quality, leads organizational efforts to obtain and retain PCMH recognition.
Establishes and implements metrics (process capability, control charts, measurement quality) for monitoring system/process effectiveness and to enable managers to make sound patient safety decisions.
Educates and trains employees to implement risk reduction activities.
Collaborates in the development of short and long-range goals for risk reduction and safety performance for incorporation into strategic planning.
Develops, modifies/updates plans and implements policies and procedures to support clinical services. Manages and monitors the distribution, compliance, and regular review of policies.
Infection Control
Assures compliance with testing and vaccination requirements for all Marillac and contracted staff.
Coordinates and oversees MarilacHealth’s procedure for blood and body fluid exposure.
Implements processes for minimizing transmission of infectious disease within all facilities.
In conjunction with the CMO coordinates MarillacHealth’s response to endemic or epidemic infectious disease events.
Advises clinical personnel on emerging infectious diseases relevant to the region.
Develops and assures compliance with employee hand hygiene protocols.
Patient Safety
Plans and implements patient safety policies and activities developed by the health center in support of National Patient Safety Goals.
Exercises oversight and collaboration with key staff to ensure the effective integration of the Patient Safety Program functions by the organization.
Collaborates with senior leadership and managers throughout the organization to ensure the health center participates in a “Just Culture” of safety. Develops staff surveys to assess culture and willingness to report unsafe practices.
Leads the response to incident reports to addresses patient safety issues and leads event analysis and development of corrective action plans. This includes initiation of Root Cause Analysis when indicated.
Collects, analyzes, and reports patient safety data to the Quality and Safety Board Subcommittee.
Patient Grievances And Patient Satisfaction
Initiates, monitors, and reports findings from patient satisfaction surveys.
Identifies and implements efforts to improve patient satisfaction scores.
Collects and evaluates patient grievances, identifying and reporting patterns.
In conjunction with appropriate management and director staff investigates all patient grievances.
Collaborate with responsible leadership in responding to all grievances.
Collaborates with operational leadership regarding patient grievances, reports grievances and action plans to subcommittee facilitates process change to address recommend improvements.
Provides the Board of Directors with a monthly summary of patient grievances and outcomes as well as summary reports of patient satisfaction data and improvement efforts.
Compliance
Develops, modifies/updates plans and implements policies and procedures to support clinical services. Manages the storage, organization and distribution of clinic policies and procedures.
Ensure bi-annual review of all clinic policies and procedures in conjunction with the policy owner.
Works collaboratively with senior leaders and CEO to ensure compliance with federal, state, and local regulatory requirements.
Manages and implements programs, policies, and practices to ensure that all departments comply with applicable law, regulations, and standards of any accrediting bodies.
Reviews policies and procedures of the clinic to determine deficiencies and ensure compliance with federal, state, and county agencies as well as active grants and regulations from accrediting agencies.
Documents laws and regulations that might affect the organization's policies and procedures.
Collaborates with other departments to direct compliance issues to appropriate personnel for investigation and resolution. Consults with attorney as needed to resolve difficult legal compliance issues.
Responds and leads investigations into violations of rules, regulations, policies, procedures, or standards of conduct by evaluating or recommending the initiation of investigation (e.g., RCA). Reports all such issues to appropriate senior leadership and CEO.
Acts as independent review and evaluation body to ensure compliance with applicable regulations and reports regularly to CEO and Board of Directors.
Accreditation
Participates in internal (e.g., Infection Control, Environment of Care) and external audits (e.g., RMHP, HRSA, CDPHE). This includes preparation for and participation in any site visits necessary to obtain or maintain designations and certifications.
Leads compliance audits against laws, policies and regulations and develops action plans with health center’s subject matter experts and leadership. Re-evaluates compliance throughout the year.
Prepares the health center for state and federal audits from planning phase thru exit conference, preparation of action plans and rebuttals.
Other Duties And Responsibilities
As a leader of the organization, be alert to and ensure that the best interests of the organization are maintained.
Perform other duties and responsibilities as required.
Competencies
Knowledge of the principles and practices of risk management, compliance, infection control and patient safety in an organization as well as in the clinical setting. Ability to evaluate and make recommendations for improvement.
Knowledge of primary care operations and Patient Centered Medical Home.
Knowledge of risk management concepts and practices.
Knowledge of applicable laws and regulations within the health care industry.
Knowledge on infectious disease control standards.
Knowledge of applicable computer systems, programs, and applications.
Ability to research, analyze, interpret complex data, and present comprehensive reports.
Skill in exercising a high degree of initiative, judgment, and discretion.
Ability to communicate clearly and effectively orally and in writing.
Required Education/Experience
Bachelor’s degree
Minimum of two years of relevant experience.
Preferred Education/ Experience
Master’s degree in a health care related field.
Three years of clinical experience in nursing or similar clinical experience.
Certified Professional in Healthcare Risk management (CPHRM) or equivalent.
Experience with risk management in governmental accredited institutions.
Experience working in a Federally Qualified Health Center or Look Alike.
Additional Eligibility
Tdap (up to date booster)
Measles, Mumps and Rubella
Varicella (or proof of immunity)
Hepatitis B
Seasonal influenza vaccine
TB Screening also required.
Seniority Level Director
Employment Type Full-time
Job Function Management and Manufacturing
Hospitals and Health Care
#J-18808-Ljbffr