Oversees all Risk Management activities including managing claims against the facility; interfacing with defense counsel; interacting with patients, medical staff and hospital staff to resolve complaints; administering the risk management program on a day to day basis; managing and analyzing the risk management data; overseeing the patient safety programs in order to maintain an environment that optimizes patient safety and reduces the likelihood of medical/health errors. Oversees all quality management activities including: performance improvement, quality review, TJC readiness, core measures management. Plans, implements, evaluates and reports on all quality functions throughout the organization. Participates in hospital and medical staff committees as required. Establishes policies and procedures as needed. Performs ongoing TJC preparedness reviews of the hospital, including national patient safety goals. Responsible for day-to-day management of the Hospital's participation with LifePoint PSOrg, LLC, including collecting patient safety information and reporting it to LifePoint PSOrg, LLC on an ongoing basis for analysis and feedback. Ensures patient safety work product is appropriately labeled and submitted to the patient safety evaluation system and reported to the LifePoint PSOrg as appropriate.

ESSENTIAL FUNCTIONS

Provides coordination and direction of the hospital?s Quality and Risk Management, Patient Safety and Compliance Program through maintenance and improvement in issues in every department throughout the hospital.

Demonstrates a consistently well-organized approach to all duties and activities assigned by the CEO.

Investigates and provides documentation on all compliance issues and hotline calls and collects and submits Compliance Dashboard quarterly

Evaluates the Risk Management and Patient Safety Programs annually, taking action on trends noted and reports results to the BOT.

Serves as liaison to insurance companies and legal counsel. Manages legal claims against the hospital and Marion Clinic. Maintains all legal case files and ensures maximum protection from discoverability of all such files.

Collects and reviews data to identify trends regarding occurrences and provides aggregation of analysis of data.

Reports to: CEO

About Andalusia Health

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