Director, Risk Management & Performance Improvement

Director, Risk Management & Performance Improvement Opportunity

Emerald Coast Behavioral Hospital provides inpatient treatment services to adolescents and adults at our 86-bed facility in Panama City, FL and outpatient services to adolescents and adults at our four outpatient centers located throughout the Florida Panhandle.

Additionally, we offer specialized treatment for active-duty military members through our Military Resiliency Program, specialized chemical dependency treatment and TMS therapy for chronic depression.

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Director is responsible for clinical identification, risk evaluation and coordination of corrective action related to risk issues and creating methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services. Leads improvement of clinical outcomes through program evaluation and performance improvement functions including monitoring programs for compliance with quality standards, implementing tools used for programs and service evaluation, and organizing data collection and information analysis.

Directs the activities of the Patient Advocate.

• Administers the Risk Management (RM) Program using TERM (Technical Elements Related to the Management of Patient Safety). This includes but has not been limited to:
  Risk Identification, RM Education, Risk Prevention Techniques, Claims and Litigation Management, Contract Review, and Measuring the Effectiveness of the RM Program. These areas include but are not limited to:
  • Manages incident reporting function. Investigates incidents, takes or recommends corrective action and identifies trends.
  • Prepares and facilitates the monthly Patient Safety Council meeting to assure all safety related concerns are addressed.
  • Prepares Probable Claim Reports for all Level III and IV Incidents, and near misses.
  • Leads internal investigations and Peer Reviews on serious and tragic incidents as well as near-misses as required. Conducts Root Cause Analysis or Intensive Analysis as appropriate.
  • Prepares risk identification reports in summary format utilizing appropriate templates. Analyzes trends. Prepares and presents risk identification reports for CEO, medical staff, Medical Executive Committee (MEC), and Governing Board.
  • Conducts Failure Modes Effect Analysis (FMEA) as required.
  • Interacts with patients and families to increase patient/family satisfaction and/or to diffuse potential litigious occurrences /perceptions.
  • Responds to Risk Management/Quality of Care concerns from outside agencies as appropriate.
• Plans, develops, coordinates, directs and carries out activities related to the facility-wide performance and quality improvement program and processes to include:
  • Ensures that the facility is in compliance with The Joint Commission, CMS, AHCA, DCF, OSHA and other regulatory agencies standards and reporting requirements. Facilitates regulatory surveys to include facility readiness, training and resolutions of findings. Processes applications and license renewals for The Joint Commission, AHCA license, and Baker Act Receiving Facility Designation. Manages facilities corporate licensure database.
  • Responds quickly and proactively to performance indicators and data, resulting in higher quality staff and superior patient care.
  • Leads CMS Chart Audit team and other initiatives to ensure compliance with regulatory standards, contracts, licensing standards and guidelines.
  • Prepares for and conducts the monthly Quality Assurance Performance Improvement (QAPI) Committee, Multidisciplinary Peer Review, and Policy and Forms Committee. Assures the continuity of all business conducted is captured and concluded from month to month. Assists leadership in developing their role in performance improvement and participation on this committee.
  • Collects and submits all externally submitted performance measures.
• Plans, organizes, and manages areas of responsibility to meet the standards set by the hospital and regulatory agencies.
  • Hires, supervises, develops, evaluates, and disciplines staff. Ensures staff is knowledgeable and competent to perform duties by providing orientation, training, and continuing education as reflected in departmental policies and records. Meets with staff members on an ongoing basis to review performance and provide feedback, guidance and instruction as needed. Assures appropriate work production and documentation in accordance with policies and regulations through audits, supervision, and goal setting.
  • Reviews performance in area of supervision in relation to established goals to include standards and criteria, audit of deficiencies and follow-up; implements changes to effect continual improvement in services provides; and assures compliance with regulatory and legal requirements.
  • Revises and maintains policy and procedure manuals.
  • Recommends fiscal or budgetary requirements necessary to maintain service within the department. Monitors department on an ongoing basis and…