· Provide the CEO with timely and accurate information related to Risk Management, Regulatory Compliance, Performance Improvement and Safety issues.
· Advise and assist Management on Risk Management, Regulatory Compliance, Performance Improvement, and Safety issues.
· Provide management and staff education as needs identified.
· Serve as a member of the Management Team and on facility committees as requested.
· Interpret and implement corporate and facility policies and procedures in accordance with law and regulatory/accreditation requirements.
· Serve as Administrator on Call as assigned.
· Define required clinical data sets in conjunction with the Medical Staff, clinical leaders and Acadia Corporate clinical and risk resources.
PERFORMANCE IMPROVEMENT MANAGEMENT
· Implement the Performance Improvement Program.
· Set expectations, develop plans and manage processes to measure, assess, and improve the quality of the organization’s management, clinical and support activities.
· Measure, analyze and manage variation in the performance of defined processes that affect patient safety.
· Establish agenda for the Performance Improvement Committee and coordinate with process owners regarding required reporting and follow up.
· Complete the monthly scorecard and upload to Acadia Share file.
· Implement the Risk Management Program.
· Identify opportunities to reduce risk exposure.
· Enter Level 1 and 2 incidents into the RiskQualHAS program.
· Lead sentinel and critical event analysis.
· Lead the hospital’s compliance program in conjunction with Corporate Compliance Officer.
· Coordinate agenda and reports for Medical Staff meetings.
· Assist the Medical Director with corrective action plans as needed.
· Coordinate with Medical Director and CEO to ensure Medical Staff Bylaws, Rules & Regulations, and Credentialing Plan are fully implemented.
· Develop, administer and oversee systems for ongoing regulatory compliance.
· Direct compliance with laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of accrediting agencies.
· Function as the point of contact with the survey team and/or Acadia Clinical and Risk focused site visits.
· Facilitate Plans of Correction or Action Plans as a result of surveys and site visits.
SUPERVISORY CORE COMPETENCIES (SKILLS)
Ability to make good decisions within assigned scope of authority.
Identifies opportunities to reduce costs associated with risk management or regulatory issues.
Coordination With Other Departments
Ability to support and effectively collaborate with other departments to achieve results.
Ability to plan ahead and to prioritize and coordinate activities, services, schedules or programs.
Ability to identify knowledge deficits through direct observation or medical record review, communicate findings to the appropriate management team member and assist in development and implementation of plans to improve staff performance.