Director of Improvement and Risk Manager

Director, Performance Improvement and Risk Management

Position Summary
Under the direction of the Chief Nursing Officer/Chief Operating Officer, the Performance Improvement and Risk Management Director is responsible for administrative, technical, and coordinating support to and for working collaboratively with the Performance Improvement Council (PIC) in the development, implementation and evaluation of the Performance Improvement Program that meets accreditation and regulatory guidelines. He/She manages and coordinates the Performance Improvement and Risk Management Programs throughout the organization.

In collaboration with the Medical Staff, Patient Care Services, Nursing, Support Services and other departments, the Performance Improvement and Risk Management Director implements performance improvement (PI) and risk management programs through department-specific and organization-wide planning, coordinates reports to the Medical Executive Committee (MEC), PIC, Board of Directors and accreditation/regulatory agencies. Facilitates the training of hospital staff in the use of performance improvement tools, performance initiatives, corrective action plans development and implementation.

Maintains current knowledge of Joint Commission accreditation standards, California Department of Health (CDPH), and Centers for Medicare and Medicaid (CMS) regulations. In addition, the Performance Improvement and Risk Management Director is responsible for coordinating hospital regulatory and accreditation survey activities.

This position requires providing administrative standards compliance supervision to departments, which provide care/service to hospitalized patients in a manner that demonstrates an understanding of the functional, and/or developmental age of the individual served.

This position requires the full understanding and active participation in fulfilling the mission of Mission Community Hospital (MCH). It is expected that the Performance Improvement and Risk Management Director demonstrate behavior consistent with the Mission Community Hospital values and shall support its strategic plan, goals, and direction of the Performance Improvement and Risk Management Plans.

SERVICE PERFORMANCE

• Greets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area.
• Asks how the customer may be helped with interest and concern.
• Listens attentively, does not interrupt.
• Accepts ownership and takes action to resolve customer needs and/or concerns.
• Is attentive and responsive to the expectations of physicians, co-workers and direct reports.
• Accepts constructive criticism and modifies actions accordingly.
• Is generous in acknowledging a job well done.

SERVICE PERFORMANCE (cont.)

• Uses words and behaviors that express consideration, concern and respect.
• Facilitates and holds staff accountable for meeting department customer service standards in the performance of duties.
• Utilizes telephone skills effectively as outlined in the Star Service Program.
• Keeps all private information about staff or patients confidential.
• Identifies customers and their service requirements.
• Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.

VALUE ADDED - INCREASES WORTH OF SERVICE TO MISSION COMMUNITY HOSPITAL

• Participates in marketing activities of the Hospital as requested, including but not limited to committees/task forces, speaking engagements, conducting tours, Hospital sponsored health fairs.
• Contributes to marketing materials such as brochures, newsletters, teaching materials.
• Participates in staff recognition activities in ways that reward behaviors reflecting positively on Mission Community Hospital.
• Engages in interdepartmental /multi-department/house-wide process improvement forums/task forces/committees.
• Offers and implements solutions to challenges/problems.
• Assist with development-related activities including fund raising programs & activities.
• Monitors the marketplace and recommends new and creative business opportunities.
• Analyzes targeted existing services and product lines for cost/benefit and develops appropriate strategies to improve growth where applicable.
• Attends/participates in activities that contribute to professional growth and development.

• Responsible for coordinating, facilitating and monitoring hospital-wide PI activities/initiatives including inpatient and outpatient Core Measure data abstraction, analysis, and committee reporting.
• Responsible for coordinating, facilitating, and monitoring patient satisfaction improvement initiatives, including data reporting to hospital committees.
• Responsible for coordinating, facilitating and monitoring hospital-wide risk management activities/initiatives including data abstraction, analysis, and reporting.
• Responsible for coordinating and facilitating hospital-wide accreditation and regulatory agency survey preparedness and readiness, which includes staff and…