Quality Improvement and Risk Manager RN

The Quality Improvement and Risk Manager is pivotal in leading and upholding the highest standards of quality, performance improvement and risk management throughout the organization. Adherence to the organization’s Philosophy, Mission and Values is an expectation of this position. This involves strategic oversight and adaptation of quality care plans, mentoring leadership and colleagues across multiple departments including both clinical and non-clinical, all while ensuring consistent quality of care.

A crucial part of the role is representing quality and performance improvement, as well as risk mitigation at the executive level, collaborating with various departments to ensure compliance with regulatory standards and promoting top-tier patient care.

This position requires staying updated with healthcare trends, working under the guidance of the appropriate leader to interpret relevant regulations, and leading initiatives to enhance patient safety and reduce errors. Additionally, the Manager will be responsible for the comprehensive management of the Risk Management program, aligning with facility goals. This position will work closely with members of the CLH Executive Leadership Team, CLH BOD and Medical Staff to ensure delivery of high-quality, cost-effective patient care in alignment with the hospital’s strategic objectives, mission, vision, values, and goals.

• Collaborate with members of CLH Nursing Administration, Hospitalists, Medical Staff and other disciplines, ensuring adherence to patient care.
• Tasked with the presentation of comprehensive Quality & Risk reports at Medical Staff, Medical Staff Executive Committee, QAPI committee and CLH BOD meetings. Additionally, this role involves reporting to any other state or federal entities as required.
• Assist and/or oversee colleague education in areas of quality, performance improvement and risk throughout CLH, while assisting in areas related to AIDET, and ICARE values.
• Support department leaders in monthly QA/PI meetings. Assisting all department leaders in QA/PI goals, data collection and ongoing projects.
• Risk Management:
  
  Plan and coordinate all Risk Management activities, directing the program development to meet organizational goals.
• Automated Incident Reporting System, including Followup:
  Oversees and manages the automated incident reporting system, database, and tracks trends of incidents by category. Learns, trains others and assists all CLH colleagues, and vendors with automated incident reporting systems, including anonymous reporting. Investigates and summarizes incidents, including talking with patients as needed. Leads any necessary debriefings and determines any needs for focused reviews with CLH Administration. These debriefings and focused reviews may also include, but are not limited to, the CLH Chief of Staff.
• Chart Audits:
  Conducts chart audits and assists with risk management compliance under the guidance of CLH Clinical Leadership, CLH Administration and CLH Chief of Staff.
• Meeting Participation and Follow Ups:
  Attend monthly operations meetings, follow up on incident reports within Risk Management, and address patient complaints or policy issues according to Risk Management guidelines.
• Budget Coordination:
  Coordinate appropriate budget proposals, assisting with appropriate clinical staffing matrices, while ensuring cost‑efficient service and treatment methods.
• Morale:
  Will follow CLH ICARE and AIDET platform.
• Healthcare Quality:
  Manage and enhance healthcare quality by overseeing inpatient and ED core measures. This involves checking the patient matrix to identify those qualifying for core measure trending, reviewing their charts for compliance, and addressing immediate concerns with staff or providers. Regularly update the CART and review the CMS website for core measure updates. Compile and analyze weekly trends for improvement and integrate monthly quality statistics into SQSS.
  
  Obtain and complete both IP and OP core measure abstractions by CMS and HCAHPS deadlines, review abstraction summary reports quarterly, address any arising concerns, and collaborate with CLH’s Florida Hospital Association Representative to identify…