Director of Performance Improvement and Risk Management
Universal Health Services, Inc.
October 8, 2018
WILLOW SPRINGS CENTER
Willow Springs Center, an affiliate of Universal Health Services, Inc., has an opening for a Director of Performance Improvement and Risk Management.Â
The purpose of this position is to plan, oversee, and direct the operations of Performance Improvement and Risk Management, including budgeting, fiscal management, program operations, compliance, and strategic planning.Â This position collaborates with other members of Leadership to attain a level of clinical excellence as indicated in the Willow Springs Center mission.Â This position is part of a team tasked to lead and take ownership for every aspect of fiscal operation and service delivery.Â This position is an essential part of the guiding force of Willow Springs Center.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Identifies areas of liability and communicates to the CEO; helps develop solutions to mitigate liability.
Assures compliance with all federal and state legal requirements.
Develops departmental policies as necessary and creates a plan to review, update, and communicate new policies and changes to existing policies.Â Stays abreast of all changes to regulatory mandates and informs subordinates of changes.Â
Establishes a system for collecting and analyzing statistical data relating to performance improvement measures and outcomes.Â Manages performance improvement data and information flow, as outlined in the IOP Plan.Â Reviews monitored data to identify trends; reports to staff and develops solutions to address trends.
Ensures deficiencies in performance improvement goals and objectives are addressed with appropriate oversight in a timely manner.
Assesses, designs, implements and directs the Risk Management Program.
Records performance improvement activities and all committee minutes associated with performance improvement programs.
Identifies and mitigates risk factors as they relate to the hospital-wide risk management program.Â Monitors progress on initiatives to mitigate risk factors.
Ensures the facility procedures meet TJC, county and state guidelines.Â Ensures the facility maintains a standard of constant readiness.
Consults with senior staff and directors in the development of department specific programs and quality measures which are within the standards of TJC, CMS, OSHA regulations and all other applicable federal, state or local law/regulations governing health-care entities.
Ensures appropriate and timely reporting of occurrences by maintaining a Healthcare Peer Review Reporting system; enters incidents into the MIDAS data base.
Collects and screens all reports; analyzes and trends data; identifies actual and potential risk situations and facilitates the determination of causative factors.
Refers occurrences for follow-up to appropriate department or medical committee; ensures that all Level III/IV are referred to the Peer Review Committee.
Receives immediate and concurrent reporting of adverse patient outcomes identified by the PI process.
Performs risk surveys and inspects patient care areas in concert with hospitalâ€™s safety (EOC) program committee objectives.
Reviews reports on facility and equipment to assess loss potential
Receives and investigates reports of product problem to determine appropriate response and establish record keeping responsibilities.Â In the event of patient injury, established direction from Corporate Risk Management in the appropriate action for defense strategy.
Receives information (verbally or formally on the HPR) from facility staff regarding patient events which may lead to a claim.
Operates to maintain and facilitate system securing hospital, employee and patient property.
Provides aggregate analysis of risk data and trend analysis of incidents to administration, Corporate Risk Management, Patient Safety Council, MEDC, Performance Improvement, Environment of Care/Safety Committee, Governing Board, Medical Staff Committees.
Directly reports to administration those incidents with claims potential.
Reports to Corporate RM any serious risk even involving actual or potential injury to patients and visitors; enters PCRâ€™s into STARS Database within 10 business days of incident.
Assists Administrator in facilitating the processing of summons and complaints served on the hospital and its employees; Reports receipt of summons and complaints immediately to Corporate Risk Management and insurance Department.
Coordinates investigation of claims within the facility including directing in-house claims investigation; preserving all pertinent information (medical record, x-rays, equipment, lab/pathology specimens, relevant reports/ policies and procedures); facilitates early reporting; establishes early control of situation; assists in obtaining materials for attorneys; maintains all legal case files and ensures maximum protection and discoverability.
Located in the heart of the Sierras, Reno, Nevada provides a destination location where employees can live, work and play.Â The location itself is a benefit; not to mention Nevada has no state income tax.
Working at Willow Springs Center means building a career that is dynamic and satisfying; having the opportunity to work and learn from some of Nevadaâ€™s leading mental health professionals; and being a part of something meaningful that changes the world, one child at a time.Â Work at Willow Springs Center is a life path.
At Willow Springs Center, we seek high performing, compassionate professionals dedicate to impacting the lives of youth ages 5 to 17 years of age.Â If you desire to make a difference through the work that you do, Willow Springs Center is the place for you.