STEWARD HEALTH CARE POSITION DESCRIPTION
POSITION: Performance Improvement/ Risk Management Specialist (PIRM)
REPORTS DIRECTLY TO: Local Director of Quality and Safety
COLLABORATES WITH: Local Primary Risk Manager if applicable
REPORTS INDIRECTLY TO: Chief Medical Officer (CMO)
This position is a dual role encompassing Risk Management and Performance Improvement. Requires a highly trained professional, with demonstrated passion for risk management and performance improvement who will work in collaboration with the Local Director of Quality and Safety to implement the activities identified in the System-wide Quality and Safety Plan consistent with board approved plans and regulatory and standard setting agencies.
Reporting to the Director of Quality and Safety, and working in partnership with the hospital CMO and Chief Nursing Officer, the PIRM is responsible for the day to day implementation of the hospital’s approved Quality and Safety Plan. Such duties include analysis and resolution of reported incidents or occurrences along with coordination of improvement activities to mitigate any future recurrence. Additionally, the PIRM supports the overall improvement strategies of the organization to support both clinical and operational excellence.
- In coordination with the Director of Quality and Safety manages all survey activities from arrival, coordination of survey activities to exit exercises inclusive of successful completion of any action plan associated with the survey process to ensure ongoing accreditation.
- Supports management of a risk identification process for the organization’s operations, departments, and services. Educates and assists other managers in assessing their areas of responsibility for exposures to loss and unsafe processes and conditions.
- Collects, evaluates, and reports on events, incidents, and claims.
- Reviews and analyzes incident reports, rates by severity and conducts all follow-up as identified from review.
- Supports investigation of all serious events. Assists with communication and documentation of errors or serious events in accordance with legal requirements and/or accreditation standards.
- Develops and maintains positive working relationships with providers, management, and staff to promote open communication and accurate flow of information.
- Supports coordination of risk and safety management orientation and continuing education programs for providers, management, and staff to enhance awareness of their role in patient safety, risk reduction, and event reporting.
- Supports activities of the patient safety triage team/grievance committee(s) and serves on other patient care and safety related committees as member, or ex officio, as needed to communicate findings, recommendations, actions, and results.
- Prepares reports of events as required by law or in accordance with voluntary participation
- Fosters and maintains collaborative relationships with external agencies.
- Provides administrative support for the department committees when applicable
- Reviews documented patient, family, and visitor concerns, complaints and grievances provided by the Patient Advocate. PIRM will support resolution and appropriate communication when indicated to both the patient and regulatory bodies.
- Attends and supports departmental/hospital meetings where measurement and evaluation functions are performed as agreed upon by the Director of Quality and Safety.
- Attends Quality and Patient Safety Committee meetings as well as collaborative group meetings when performance improvement is indicated.
- Assists with the annual evaluation of the Quality and Safety Plan
- Assists departments with the development, implementation of hospital tracking system for quality and risk management activities
- Assists departments with integration of quality and risk activities
- Reviews departmental quality and safety indicators for compliance, appropriateness and rationale
- Understands and implements programs related to patient safety indicators located from local and national regulating bodies.
- Acts as liaison to statewide and national collaboratives for quality and safety
- Completes chart abstraction for quality and safety related programs.
- Conducts FMEA analysis when high volume, high risk opportunities as discovered through incident report analysis. Organizes team, creates process maps, creates failure modes analysis, identifies prevention and/or corrective action strategies and implants as identified.
- Understanding and implementation of programs related to national and local patient safety initiatives.
- Performs all other job related duties as requested by Quality and Safety Director
- BS or MS in health care field preferred with recent hospital operations experience. CPHRM and/or CPHQ preferred
- Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
- Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.
- A highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organizational, political, and perceptual issues associated with change.
- Results orientation accompanied by the skill set required to conceptualize, implement, and operationalize a user-friendly clinical excellence and patient safety program.