Risk Manager - Quality Management

Navajo Preference Employment Act

In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.

Overview

POSITION SUMMARY:

This position is located within the Quality division within the Tuba City Regional Health Care (TCRHCC). Incumbent is responsible for the management, development, administration, education of staff, and documentation of all risk management and issues for TCRHCC to include all external extensions of the hospital. Compliance with the risk management standards is required for TCRHCC accreditation by The Joint Commission (TJC), in addition to other federal, state and tribal regulations. Data generated through this program provides a basis for establishing hospital-wide policy and for identifying trends, and issues for further study, improvements, and/or corrective action by directors, department heads, and/or healthcare providers and the senior executive team.

Qualifications

NECESSARY QUALIFICATIONS:

Education:

Bachelor of Science in Nursing

License and Certification

A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States.

Experience:

(5) years' experience in a healthcare setting with experience in directing and implementing major processes relating to health care issues, such as, performance improvement, risk management and patient safety issues, process improvements and effective communications to promote proactive and corrective actions relevant to identified risk issues.

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

• Ability to provide in-depth reports to a variety of audiences in a succinct and timely manner
• Knowledge of TCRHCC mission, healthcare agencies, hospital self-assessment programs and TJC accreditation requirements, including performance improvement, risk management, infection control, safety, patient safety (and National Patient Safety Goals) and utilization review.
• Knowledge of the Privacy Act, Health Insurance Portability and Accountability Act (HIPAA), safety, security and claims investigation, patient advocacy/ombudsman policies and procedures
• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences
• Strong writing, interpersonal communications, organizational and computer skills
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading, or incomplete information, as determined by TCRHCC.

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:

The Incumbent must have the ability to sit, stand, walk, drive, crouch, twist, maintain balance and reach for prolonged periods meaning greater than 3/4 workday. Must be able to frequently (1/2 workday) climb, kneel, and bend. Incumbent must be able to lift, push and pull up to 100 pounds on occasion, may frequently be required to lift up to 10 lbs and push/pull up to 25 lbs. Must also have the ability for far vision, near vision, color vision, depth perception, seeing fine details, hearing normal speech, telephone use, and, hearing overhead pages through a loudspeaker for prolonged periods of time (3/4 workday). Incumbent must have the ability with simple grasping, firm grasping, fine manipulation and use of keyboards for prolonged periods (3/4 of workday). The position is mostly sedentary, frequent standing, walking, and bending to make presentations and to perform functions of investigation; light to moderate reaching, lifting in the performance of normal office functions.

Mental:

Incumbent must have the mental and emotional ability for prolonged periods of time to: cope with high level of stress; make decisions under high pressure; concentrate; handle a high degree of flexibility; handle multiple priorities in stressful situation; work alone; demonstrate high degree of patience; and, work in areas that are close and crowded. Incumbent is expected to frequently cope with anger/fear/hostility of others in a calm way; and manage altercations. Occasionally the incumbent may need adapt to shift work.

Environmental:

Incumbent may be exposed frequently (1/2 workday) to infectious diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights and loud noises.

Responsibilities

ESSENTIAL FUNCTIONS

• Responsible for the management, development, administration, evaluation, and documentation of the risk management program for the TCRHCC.
• Prepares risk management program plan, and a yearly evaluation of program effectiveness, and trends and analyzes risk management data. Additionally, provides an annual report to Senior Leadership Committee (SLC), Performance Improvement Committee (PIC) and Board of Directors (BOD).
• Responsible for the orientation and education of TCRHCC staff to address of risk management procedures, techniques and regulations. Collaborates with the Patient Safety Officer to train and assist staff with the occurrence reporting system, tracks issues, analyzes and refers them to the appropriate work center for resolution.
• Reviews daily House Supervisor's reports for key identified issues of risk; Attends daily Safety Huddles.
• In collaboration with the Patient Safety Officer, tracks and reviews incident reports relating to patient safety, and has the authority to investigate verbal or written reports containing actual, questionable or potential Risk Management issues.
• Serves as a member of the Performance Improvement Committee (PIC), Safety Committee and identifies facility-wide issues and recommends appropriate action to the PIC, Chief Quality Officer, and/or Chief Executive Officer (CEO), as appropriate.
• Performs chart reviews of patient records to gather, analyze and trend data, and makes recommendations to the PIC.
• Identifies tracks and documents all Potentially Compensable Events (PCE) in the facility. Obtains Peer Review or other reviews when appropriate, and assures corrective action is taken. Maintains documentation and assures communication to and from all appropriate staff, under the direction of the Chief Quality Officer and Chief Compliance Officer.
• Research and assesses allegations of unacceptable patient care and provides recommended solutions, implementation monitoring and follow-up.
• Identifies Sentinel Events and coordinates Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), as appropriate, and provides reports provided to appropriate staff in collaboration with the Chief Quality Officer.
• Collaborates with the Chief Compliance Officer and Chief Quality Officer in coordinating and tracking all tort claims; Maintains tort files in a secure manner. Notifies and works with providers named in a tort claim; duties with collaboration with the Chief Quality Officer and Chief Compliance Officer.
• Coordinates malpractice subpoenas received for TCRHCC; under the direction of the Chief Quality Officer and Chief Compliance Officer, works with the US Assistant Attorney, Navajo Area Office, IHS Regional Counsel, TCRHCC general legal counsel and TCRHCC staff to assure strict adherence to the correct process. Coordinates depositions and interviews, including arrangements for room reservations, scheduling, document presentation and maintenance of records.
• Consults with legal counsel in the formulation and review of TCRHCC policies and procedures that could have an impact on the facility's liability or risk control.
• Develops proactive responses to patients, their families, and employees following the investigation of potentially compensable events and asserted legal actions.
• Coordinates with Clinical Staff for electronic health records data entry pertinent to patient services provided or with interventions provided regarding risk management issues
• Performs other duties as assigned.