The Director of Risk Management is responsible for the ongoing, effective operation of various patient safety and risk management activities. Such responsibilities include, but are not limited to: performance and oversight of the claim management functions including investigation and analysis, performance of risk assessments including new services, performance of root cause analysis for the system including action plan tracking and facilitation, and management of the Patient Safety Council with incorporation of the corporate TERM program into the overall risk management program. Works collaboratively with department directors and the executive team to implement Corporate and Facility risk reduction strategies. Provides expertise to regulatory and compliance standards and processes. Position entails data analysis, reporting, educating, providing leadership and being accountable for related activities.
ESSENTIAL JOB DUTIES AND RESPONSIBILITIES
§ Planning – Assist with budget preparation for assigned department(s).
§ Meeting Objectives – At a minimum, the department operates within stated budget guidelines as measured by the specific unit of service, with the goal of exceeding budget projections.
§ Cost Control – Effectively controls department costs and prepares for fluctuations and unexpected costs. Identifies cost reduction opportunities on a regular basis, and recommends implementation when necessary.
§ Productivity – Monitors and assists leadership with adjusting FTE levels to achieve budgeted staffing based on volumes, organizational goals, accepted staffing models within the industry, and patient care needs defined by law, physician orders and/or a standardized nursing workload measurement system.
§ Service Excellence – Treats everyone with dignity and respect and encourages collaborative relationships with colleagues, community providers, patients and family members. Documents all customer service responses and consistently identifies ways to improve customer service and feedback while reducing customer/patient complaints.
§ Policy Development – Develops and implements laws and procedures that guide and support the provision of services.
§ Recruitment/Staffing – Maintains adequate staffing levels and responds to shortages/turnover as required with a minimum impact on services; recommends a sufficient number of qualified and competent persons for providing care and treatment.
§ Retention – Takes appropriate action and interventions to retain quality staff. Notifies HR of employee resignation providing adequate notice for exit interview and processing. Maintains department turnover at or below facility annual goal.
§ Performance Management – Determines the qualifications and competence of department personnel who provide services and who are not licensed as independent practitioners. Provides continuous feedback to employees and processes 90-day and annual evaluations by the due date 100% of the time. Develops, counsels, disciplines and terminates staff as necessary, following all hospital human resources policies. Reviews and evaluates the work and productivity of staff.
§ Staff Requirements – Assures timely compliance with staff job requirements to which may include, annual FIT Testing, TB, Flu Vaccination, LMS, licensure and certifications.
§ Staff Development – Identifies the learning needs of all staff and contributes to meeting those needs. Teaches others in areas of expertise. Identifies own education needs and seeks appropriate learning experience.
§ Conflict Resolution – Provides mechanisms for open feedback and communication from staff. Identifies situations of potential conflict and provides timely intervention always following policy and procedures utilizing appropriate resources.
§ Flexibility/Adaptability – Displays positive traits and qualities needed for a successful manager; has the ability to work with changes in the environment and participate as a team player.
§ Initiative – Takes the responsibility for creating innovative programs and continuously strives to improve department services and organizational performance. Establishes and implements department goals and objectives in order to improve service delivery.
§ Medical Staff – Maintains a positive relationship with the Medical Staff and identifies opportunities to improve service relations.
§ Employee Recognition – Utilizes Service Excellence program to recognize and reinforce exceptional customer service and staff performance.
§ Rounding – Actively rounds on patients and staff. Acts as a resource for interdisciplinary care rounds.
§ Department Communication – Conducts regular staff meetings and provides written minutes for staff. Communicates facility wide information/updates as appropriate.
§ Interdepartmental Communication – Collaborates with peers and demonstrates innovative use of system wide resources to facilitate consistent practices, policies, and appropriate utilization of staff.
§ Town Hall Meetings – Encourage department staff participation at Town Hall meetings with a goal to exceed 50%.
§ Employee Engagement Survey– Staff participation in bi-annual survey meets or exceeds 80%. Action plan results are used to identify areas of opportunity and an action plan is developed and implemented.
§ Committees/Work Groups – Encourages and facilitates staff level participation in committees and work groups.
§ Facility Moral Building Activities– Encourages and facilitates staff level participation in facility sponsored events.
§ Process Improvement - Leader is actively engaged in PI process, using data to drive improvements.
§ Quality Targets - Supports and participates in the facility Performance Improvement Plan, goals and initiatives.
§ Regulatory - Leader is actively engaged in maintaining survey readiness. Areas of opportunities are corrected timely.
§ Submits performs improvement data to Quality Council monthly.
§ Participates in Emergency Preparedness Drills. Demonstrates through practice drills and upon request understanding of his/her role in the event of an emergency or disaster.
§ Is a standing member of the new hire orientation program; facilitates hospital education activities and in-services as presented down from corporate risk management and/or corporate compliance.
§ Responsible for development, review and revision of departmental written policies and procedures.
§ Ensures that the department has equipment, supplies necessary to provide consistent quality and service delivery.
§ Reports any unsafe situations or safety hazards immediately. Labels and removes any malfunctioning equipment from service and notifies Engineering.
POSITION SPECIFIC RESPONSIBILITIES:
§ Risk Management Program Administration:
o Serves as a resource to senior leadership, facility and medical staff. Participate in 24-hour call.
o Made aware of all serious incidents ensuring thorough investigations and notifications to senior leaders, and UHS Risk as warranted.
o Reviews and updates the Risk Management Plan, Goals and Objectives yearly.
o Serves as the hospital’s Patient Safety Officer.
§ Risk Identification:
o Is responsible for maintaining the risk management database and notifies Sr. Director Corporate Risk Management and/or Corporate Group Risk Manager of all G. H. I incidents.
o Oversees and participates in facility risk assessments for clinical and non-clinical areas
o Participates in RCA’s and FEMA’s and ensures submission to Corporate Risk Management
o Participates in the peer review process and presents serious incidents, when applicable
§ Risk Management Education:
o Participates in the new employee orientation for discussion of the Risk Management Program, Patient Safety, incident reporting and TERM
o Acts as a resource for issues (i.e., consents, confidentiality, documentation, ethical, standard of care, compliance)
o Promotes Best Practices by educating facility and medical staff on risk management issues.
§ Risk Prevention Techniques:
o Participates in the development, implementation and review/revision of policies and procedures.
o Collaborates with clinical leaders to actively work and establish compliance with standards of care, best practices in industry accepted high-risk areas (i.e., ED, ICU, Surgery, OB, medication administration, fall prevention)
o Collaborates with the leadership team to promote positive patient/family/visitor experience.
o Works collaboratively with security and Human Resources to enforce facility safety practices (i.e. visitation, workplace violence, identification /harm prevention regarding patient belonging’s, and disclaimer for liability of vehicles parked on facility property
§ Measuring Effectiveness and Risk Management Program:
o Provides reports to Corporate Risk Management, as per established guidelines
o Complies and reports Midas RDE analysis and trends to appropriate individuals, departments and committee to be utilized for improvement of patient care
o Provides confidential reports of significant occurrences and incidents to applicable peer review committees and PSC
o Administration ensures the presentation of risk management information and reports are presented to the peer review committee by either the Director of Risk Management/Accreditation or the Director of Performance Improvement/Patient Engagement
§ Claims and Litigation Management:
o Directs and participates in the investigation of serious incidents concurrently with guidance from corporate risk management. Works with CBO regarding suspension of bills
o Timely forwarding of claim notices and submission of Probable Claim Reports
o Through administrative support develops and institutes policies and formalizes receipt of claims notices, securing evidence and confidentiality of information and material relating to claims.
o Concurrently informs Corporate Insurance, Risk Management and Senior Facility Executives of attendance on any pending trials, mediations, or depositions and submits report of activity.
§ Document Control Administrator (DCA):
o Oversees and manages the Policy Tech Navex program and application
o Provides education and guidance to management team on creating, revising, and submitting documents
o Is a resource to facility on navigating through the program.
§ Facility Compliance Officer:
o Oversees and manages the facility compliance program: meetings, education, trainings, annual work plan reviews.
o Is a resource for all compliance regulations including but not limited to: OIG audits, LEIE exclusions, Physician Non-Monetary Gift Log Audits.
Bachelor's degree from an accredited College or University in related field required in a clinical area.
Master's degree from an accredited College or University in related field preferred but not required.
Three Five (3) to Five (5) years of clinical experience in Risk Management or Quality Improvement required.
Minimum three (3) years leadership experience in Risk Management preferred but not required, acute care experience preferred.
Certified Professional in Healthcare Risk Management (CPHRM) certificate preferred but not required.
Current clinical license up to date.
Certified Professional in Healthcare Risk Management of Certified Professional in Healthcare Quality preferred but not required.
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
We believe that diversity and inclusion among our teammates is critical to our success.
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.
Employer will assist with relocation costs.
Internal Number: 2021-76085
About Doctors Hospital of Laredo
Doctors Hospital of Laredo, in Laredo, TX, is a 183-bed acute care facility that offers a range of medical services, including 24-hour emergency care, weight-loss surgery, wound care and hyperbaric medicine and comprehensive women’s health services.