Director of Risk & Quality Assurance

Job Description

Job Description

Reporting to the Chief Legal and Compliance Officer (the “CLCO”), the Director of Clinical Risk and Quality Assurance (the “Director”) defines and develops the organization's clinical risk management program under the auspices of the Quality Assurance Committee and the Ambulatory Surgery Center (ASC) Quality Assessment and Performance Improvement Committee (QAPI), oversees the Medical Staff Office (MSO), oversees the Employee and Patient safety team, and directs the efforts of the Patient Relations team. The Director works closely in collaboration with the Directors of Compliance, Operations, and the ASC to develop policies and programs for risk mitigation, infection prevention, and to ensure all accreditation, licensure and other regulatory requirements are met for InterMed’s various practices and support services.

CORE RESPONSIBILITIES :

• Develops, manages, and oversees InterMed’s Risk Management programs, including development and oversight of the annual Risk Management Work Plans.
• Completes a bi-annual Comprehensive Risk Assessment inclusive of all InterMed operations and ensures proper focus and prioritization of identified risk areas; conducts other risk assessments as necessary.
• Ensures implementation and oversight of effective corrective actions or mitigations for any identified area of risk or non-compliance.
• In collaboration with the CLCO, prepares programmatic content, meeting agendas and materials for the Quality Assurance Committee, the QAPI Committee, the Compliance Oversight Committee, and the Patient and Safety Subcommittee
• Works closely with the Chief Medical Officer / Chair of the Quality Assurance Committee, and Board Secretary / Chair of the Compliance Oversite Committee, to develop programmatic and meeting content for their respective committees.
• Oversees the Safety Program, providing direct operational supervision for the Safety Administrator and their direct reports and ensuring all staff have received appropriate training related to safety and clinical risk management
• Collaborates closely with Facilities leadership to ensure a safe and compliant environment of care including, but not limited to compliance with OSHA standards, CMS regulations and AAAHC guidelines.
• Directly supervises the Medical Staff Office Manager and directs the programmatic development and deployment of InterMed’s credentialling, privileging, and professional competence review activities as carried out by the MSO.
• Will support the MSO manager to complete implementation of software for the management of medical staff credentialling, professional competencies and the OPPE and FPPE process
• Acts as a consultant to physicians, NP / PAs and clinical teams regarding risk management services and clinical best practices for patient safety.
• Utilizes knowledge of clinical settings, scope of practice limitations, and best practices to provide clinical consultative services on risk prevention and mitigation strategies.
• Supports the Director of the ASC to ensure compliance with CMS licensure and AAAHC accreditation requirements
• Develops, maintains and implements policies and procedures related to loss prevention, patient safety, risk mitigation, patient rights and / or the organization’s responsibilities, and infection prevention, incorporating clinical best practice or other professional guidelines as applicable to the care setting
• In collaboration with the Clinical Pharmacist(s), provides oversight of the medication, supplies, and equipment policies for the organization, including the recall process
• Conducts or oversees as appropriate the investigation of accident and incident reports to determine appropriate response.
• Reviews and analyzes all occurrence reports for risk management, quality of care, regulatory and insurance concerns.
• The Director will lead or oversee the investigation and management of all significant adverse events, and conduct Root Cause Analyses as indicated
• Will ensure that risk management data are collected, analyzed, trended and used to guide the development and implementation of risk management educational programs for staff and providers.
• Prepares or oversees the preparation of incident summary reports that include all required documentation for investigations, activities and resolutions related to the reported incident(s).
• In conjunction with appropriate staff, assists in identifying potential clinical risk through risk assessment, analysis of incidents, and near miss incidents, periodic safety inspections, and / or audits. Make recommendations to reduce, prevent or eliminate risks identified.
• Identifies organizational risk through trend analysis of incidents, incident letters, reports etc.
• Maintains a risk assessment database and liaises with managers and department heads on concerning incidents or issue trends
• Keeps abreast of and complies with risk-related state and federal regulatory standards.
• Supports the CLCO to fulfill formal and informal legal discovery requests, board of medicine complaints, and supports staff in legal claims, assists legal counsel with on-site response to general legal questions
• Collaborates with Operations, Facilities, Clinical Training, and Employee Safety on the development and implementation of the Clinical Risk Management Plan

Leadership Competencies

Overall accountability and management of staff

Models behaviors that demonstrate service excellence to staff and focus on the patient as the primary customer.

Works in partnership with the clinical teams, practice leadership, and senior leadership teams.

Assess current state of department with relation to existing InterMed goals and plans.

Demonstrate knowledge and understanding of patient privacy rights under HIPAA (Health Insurance Portability and Accountability) guidelines. Maintain confidentiality related to financial, or other sensitive materials and information in printed, electronic, or verbal form, which may jeopardize the privacy of patients and / or employees. Accesses and uses the minimum necessary patient identifiable information to perform job responsibilities and duties and only for authorized purposes.

MISSION AND VALUES :

KNOWLEDGE, SKILLS, AND ABILITIES :

Registered Nurse (BSN) required; other licensed clinician types may be considered

Exceptional ability to communicate with physicians, NP / PAs, leaders and staff across all areas and levels of the organization as well as with patients and their families.

Unencumbered active registered nurse licensure in state of Maine

InterMed is an equal opportunity workplace and prohibits discrimination or harassment of any kind. We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, gender identity and / or expression, sexual orientation, marital status, disability, veteran status, or any other basis protected by applicable federal, state or local law.