Director of Risk & Quality Assurance

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

• Personnel Management  
  • Overall accountability and management of staff 
  • Regularly assess developmental opportunities for staff, coach staff to enhance performance, and support staff in learning and applying new skills and competencies. 
  •  Coordinate and monitor staffing levels and labor efficiency.
  • Approver for staff payroll biweekly in accordance with payroll department guidelines and schedule.
  • Mentors and counsels’ staff to include initiating Performance Improvement plans. 
  • Works with the Compliance and Human Resources teams to assure compliance with State, Federal and OSHA (Occupational Safety and Health Administration) requirements for staff. 

• Leadership  
  • Models behaviors that demonstrate service excellence to staff and focus on the patient as the primary customer. 
  • Leads Lean Six Sigma initiatives for the department to foster a culture of continuous improvement. 
  • Fosters intra-departmental support and collaboration between all sites. 
  • Monitors department performance and creatively seeks solutions to foster quality improvement. 
  • Develop and maintain an open and effective line of communication with employees. 
• Communication  
  • Works in partnership with the clinical teams, practice leadership, and senior leadership teams.  
  • Fosters strong working relationships with all levels of the organization to facilitate effective communication and to connect front line staff’s daily priorities to the organization’s strategic goals.  
  • Demonstrates strong interpersonal savvy.  
• Strategic Planning and Program Coordination  
  • Assess current state of department with relation to existing InterMed goals and plans. 
  • Develops proactive plans to ensure InterMed’s positioning as a leader in healthcare in alignment with company KPIs. 
  • Monitors budgets to identify potential financial overruns and variances; makes appropriate recommendations to alleviate financial implications. 
  • Champions interdepartmental problem solving.
  •  Ensures appropriate departmental policy development and adherence.
•  Confidentiality
  •  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.
• Maintains strict confidentiality in alignment with HIPAA (Health Insurance Portability and Accountability) guidelines and InterMed policies.
• Perform other duties to support the mission, vision and values of InterMed.

MISSION AND VALUES:

• Follows InterMed’s mission to provide patient-centered primary care, putting the patient first to deliver high quality, high value care.
• Provide the highest quality care to our patients with a level of service that exceeds their expectations.
• Maintain a positive attitude and always treat our patients and each other with dignity and respect.
• Insist on honesty and integrity from each other and our business partners.
• Make teamwork a core component of our relationships between physicians, staff, and patients.
• Embrace change to better serve our patients.
• Use business practices that feature individual accountability and group responsibility to ensure delivery of high value healthcare.
• Have fun as we carry out our mission to serve.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Education:
  • Registered Nurse (BSN) required; other licensed clinician types may be considered
• Experience:
  • 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.
  • Exceptional ability to thrive and have fun in a high pressure, high stakes environment
  • Proven track record in leading high functioning, multidisciplinary teams comprised of clinical and non-clinical professionals.
  • Knowledge of investigation science and ability to conduct best practice investigations.
  • Infection Prevention knowledge of guidelines and best practice; certification preferred.
  • Ability to conduct effective Root Cause Analyses using best practices.
  • Disclosure of unanticipated outcomes including medical errors to providers and patients
  • Identification of Potentially Compensable Events (PCEs) including incidents that may lead to potential claims, and demonstration of good judgment in providing early notification to other individuals (e.g., Legal; Compliance; Chief Medical Officer) once identified.
  • Accurately and succinctly presents cases to legal, compliance, or physician leadership in a timely manner
  • Serves as resource and subject matter expert for any risk related issues/information.
  • Able to correctly analyze and interpret data and convey meaningful results.
  • Able to effectively represent Clinical Risk Management at various InterMed committees.
  • Excellent presentation skills.
  • Excellent critical thinking skills, decisive judgment and the ability to work with minimal supervision.
  • Must be able to work in a stressful environment and take appropriate action, as well as engage in self-care to ensure long term success.
  • Follows standard precautions using personal protective equipment as required
  • Ability to obtain N95 medical clearance required.
• License/Certifications:
  • Unencumbered active registered nurse licensure in state of Maine
  • Other licensed clinicians will be considered commensurate with education, knowledge, skills and acquired experience.
  • Certification in Risk Management required; Certified Professional in Healthcare Risk Management (CPHRM) strongly preferred; other appropriate certification(s) may be considered.

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.