Risk Management Coordinator - Full Time/Days - Quality Management & Clinical Safety - #2030348047

Brief Description

Job Objective:

Under the direction of Quality Improvement Management or designee, the Risk Management Coordinator's primary duties include the prevention, reduction, and control of loss to the healthcare organization, patients, visitors, volunteers, physicians, other healthcare professionals and employees. The Risk Management Coordinator interfaces with all healthcare professionals in the accomplishment of these objectives.

Duties and Responsibilities:

• Conducts incident investigation and analysis through tracking, trending, education evaluation and identification of clinical and environmental
• Monitors, tracks and follows-up on internal actions needed for product
• Conducts investigation regarding patient complaints/grievances.
• Conducts critical incident
• Development of corrective action plans for problems uncovered by risk assessments, audits and investigations.
• Assists Director with contract
• Reviews, revises, and develops policies and procedures to current best practice, legislative and regulatory
• At least annually, and when a new program is added, conducts a risk management program assessment with recommendations for Leadership as
• Patient Safety:
• Collaborates with the Quality & Clinical Safety Coordinator to assess patient safety and staff awareness within the organization through the annual Culture of Safety
• Participates in walking
• Assists with conducting a high-risk process analysis (FMEA)
• Assists with conducting Root Cause Analysis (RCA)
• Assists with reporting of events outside the organization as
• Promotes a safety culture and a just
• Develop, implement and maintain risk management data collection and analysis systems including elements of:
• Written incident reports
• Referrals by staff, committees, or other departments
• Patient complaints and satisfaction surveys
• Prepares statistical and qualitative risk management reports from internal sources including but not limited to the adverse event monitoring system.
• Completes medical record reviews needed by the Claims
• Assist Director Risk and Regulatory in the Joint Commission Survey Readiness and actual survey.
• Reports to TJC ARC (Accreditation Readiness Committee) team the status of the PPR self-assessment, continuance compliance action plan, identified roadblocks to improvement and other related regulatory activities.
• Coordinates and facilities TJC functional chapter teams to achieve compliance through appropriate process improvement activity.
• Oversees the development and implementation of an action plan for each of TJC functional chapters to ensure consistency and correction of identified non-compliance issues.
• Participates in TJC rounds in conjunction with Patient Safety, Environmental Rounds, and/or patient and system tracers.
• Coordinates the implementation of necessary changes in practice, policy and procedures to maintain compliance with changes in regulatory requirements.
• Participates in Policy Oversight to ensure updates and revisions are consistent with regulatory requirements.
• Design, implement and maintain educational programs on risk management and patient safety-related topics for Leadership, medical staff, nursing and other clinical staff.
• Collaborate with the Compliance Officer and Regulatory Coordinator to promote compliance with regulatory requirements through policy development, guidance, or education.
• Americans with Disabilities Act (ADA).
• Occupational Safety and Health Administration (OSHA).
• Patient Self-Determination Act (PSDA).
• Health Insurance Portability and Accountability Act (HIPAA).
• National Practitioner Data Bank (NPDB).
• Emergency Medical Treatment and Active Labor Act (EMTALA/COBRA).
• Safe Medical Device Act (SMDA).
• Health Care Quality Improvement Act (HCQIA).
• Food and Drug Administration (FDA).
• Centers for Medicare and Medicaid Services (CMS).
• New and ongoing Federal/State regulations such as the
• Provide for the education of staff on regulatory issues related to risk management.
• Maintain awareness of patient safety activities occurring locally and nationally, related to:
• The Joint Commission (TJC).
• National Committee for Quality Assurance (NCQA).
• National Patient Safety Foundation (NPSF).
• Institute for Healthcare Improvement (IHI).
• National Quality Forum (NQF).
• Patient Safety
  
  

Southern California Patient Safety Collaborative

• Other duties required from the Quality Management Department Director as needed.
  
  

Non-Essential Duties:

Knowledge, Skills and Abilities:

Knowledge

• Demonstrated expertise in systems analysis and management skills at a minimum of an assistant director
• Current knowledge of Regulatory and Accrediting bodies such as CMS, Joint Commission, California Department of Public Health and insurance
  
  

Skills

• Interpersonal skills including verbal communication for staff education, patient interaction as needed and medical
• Additional leadership level skills, such as motivating staff and being a change
• Computer skills to include data entry. Working knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, Word and Visio).
  
  

Abilities

• Ability to work effectively with hospital and medical staff professionals in interdisciplinary settings.
• Skill and ability to follow the established Customer Service Expectations and
• Ability to comprehend, relate, or apply knowledge to new or changing situations, and strong ability to synthesize information determine solutions and usefulness of solutions
  
  

AVMC Values: All AVMC Employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.
  
  

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Absenteeism and Tardiness Policy.
• Ability to adhere with AVMC Leaves of Absence Policy.
• Ability to adhere with AVMC Paid Time Off (PTO) Policy.
• Ability to adhere with AVMC Recording of Hours Worked Policy.
• Ability to adhere to the department dress code.
• Ability to organize work and establish priorities.
• Ability to expand on own initiative in performance of duties.
• Skill and ability to follow the telephone etiquette/standards.
• Conforms to AVMC Standards of Excellence.
• Ability to function effectively under pressure and meet time parameters.
• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.
• Ability to maintain the confidentiality of patient, hospital and department information.
• Ability to adhere to safety rules and regulations.
• Safely and effectively uses all equipment necessary to carry out duties.
• Ability to interpret and function under hospital and department policies and procedures.
• Conforms with required and appropriate Joint Commission requirements.
• Conforms with and supports hospital quality assurance and improvement guidelines.
• Ability to participate effectively in department and hospital staff education.
• Display a willingness to work as a team player.
• Ability to give and support the highest level of patient/customer satisfaction at all times.
• Supports and adheres to the values and mission statement established by the AVMC Board of Directors.
• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
• Ability to follow the Code of Conduct.
  
  

Physical Requirements and Working Conditions:

• Work is performed in a busy office setting, Committee meetings, and patient units such as to review a medical record or speak with a patient/family.
  
  

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

NOTE: THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB. THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.

APPROVALS:

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Manager/Director (Initiator) Date

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Department VP/Chief Date

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HR Director or designee Date

Requirements

Education and Experience:

Education

• Bachelor of Nursing or related field or equivalent experience required.
• Master of Nursing or Master’s in related field preferred.
  
  

Experience

• Recent experience as a Risk Management Coordinator in an acute care facility preferred.
• Experience or training in statistical methodologies and data analysis
  
  

Required Licensure and/or Certifications:

• Risk Management certification, or eligibility preferred.