General Summary of Duties: Coordinates QI/Risk Management programs for a surgical facility. Responsible for promoting safe and efficient work environments for all staff members. Coordinates market and/or facility wide programs for the continuous improvement of the quality of care and service delivered to all customers - patients, physicians, employees and payors. Assist with providing patient care support as needed.  

SUPERVISOR – Center Administrator

CLASSIFICATION - Exempt

SUPERVISES - None

OPERATIONAL DUTIES INCLUDE BUT ARE NOT LIMITED TO:

• Oversees the collection, compilation, analysis and presentation of evidence based measure data as assigned.
• Prepares and presents requested reports regarding findings and outcomes of measures.
• Assists with implementation of Best Practices program.
• Maintains and generates monthly best practice reports.
• Distributes Service Quality Index scores appropriately.
• Facilitates a team-oriented approach to process improvement and problem solving.
• Assist team leaders in scheduling of meetings and act as facilitator for meetings when needed.
• Provide periodic reporting of process improvement activities/QI studies to QI Committee, Medical Executive Committee (MEC) and Governing Board (GB) generally on a quarterly bases and upon request.
• Develops and manages Peer Review process.
• Oversees safety in-services/program, including fire drills, disaster drills, including mock codes, Malignant Hyperthermia drills.
• Performs monthly tracking and trending of patient satisfaction survey feedback and reporting to QI committee. Coordinates implementation of corrective actions as required.
• Assist in maintenance of requirements from OSHA, CMS, AAAHC, and federal agencies related to quality improvement, risk management, and quality of care.
• Locates and organizes all service contracts and tracks renewal and compliance.
• Maintains documentation of preventative maintenance activities.
• Initiates annual review of policy and procedure manuals.
• Submits new/revised policies and procedures to QI Committee, MEC, and GB for approval.
• Coordinates preparation for State/Federal inspections and accreditation surveys.
• Promotes focus on customer satisfaction with all employees and management staff.
• Adheres to concepts of continuous quality improvement at all times and encourages all staff to utilize the tools learned in local training sessions.
• Schedules training sessions in continuous quality improvement for new employees.
• Maintains and implements a variance reporting system for the center.
• Receives and reviews all variances generated by personnel at the center.
• Investigates and analyzes all variances; actual and potential risks at the center.
• Follows up on all variances until situation is resolved.
• Reports significant variances until situation is resolved.
• Follows up and maintains appropriate reporting and documentation of employee exposures to blood borne pathogens.
• Takes steps to ascertain that risks are minimized through follow-up and actions on all regulatory/insurance survey report recommendations/deficiencies.
• Functions as the center’s Infection Control Nurse, if required.
• Coordinates distribution of Infection Control/Complication queries to all surgeons on a monthly basis. Track and trend return of responses and report to QI Committee, MEC, and GB on a quarterly basis.
• Follows up report of any infections/complication to Administrator/Medical Director as appropriate.
• Reviews pathology reports monthly. Maintains pathology reports and summarizes for QI Committee, MEC, and GB quarterly.
• Audits and reports variance patterns and trends to Quality Improvement Committee, MEC, and GB to identify actions to be taken.
• Prepares reports and summaries on all risk management findings on a quarterly basis to the Quality Improvement Committee, MEC, and GB.
• Communicates relevant risk management findings with Administrator, Center Managers, and Medical Director on an ongoing basis.
• Provides risk management education to staff per state and accrediting agencies requirements and when needed.
• Notifies center’s claims representative of all actual and potential claims, and ensures PCR’s are completed, when necessary.
• Functions as a liaison with the claims representative and attorneys; and provides information as required for the management of cases.
• Maintains risk management and legal files in a confidential and appropriate manner.
• Coordinates actions relating to reports of product problems (e.g., drug devices, equipment, and food recalls).
• Assists with managing the Workers Compensation program in coordination with Human Resources.
• Conducts or delegates responsibility to conduct facility safety audit on a quarterly basis.
• Evaluates patient and/or family complaints/grievances in conjunction with Administrator/Center’s Managers and assesses risk to center and ensures appropriate responses, per center’s policy and procedure.
• Coordinates and oversees center compliance with Safe Medical Device reporting and tracking.
• Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”
• Other duties as assigned

KNOWLEDGE, SKILLS & ABILITIES

• Organization - proactively prioritizes needs and effectively manages resources
• Knowledge of operating room/PACU/Pre-operative standards/techniques.
• Ability to instruct and manage personnel, both professional and non-professional.
• Ability to gather and analyze data and prepare management reports.
• Ability to speak clearly and distinctly.
• Takes initiative and exercises good judgment.
• Maintains high level of confidentiality at all times.
• Adaptability -Alertness and adaptability to change in situation.
• Communication - communicates clearly and concisely. Must be able to communicate effectively with patients and their family members, physicians, co-workers and center management.
• Leadership - guides individuals and groups toward desired outcomes, setting high performance standards and delivering leading quality services
• Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
• Tactical execution - oversees the development, deployment and direction of complex programs and processes
• PC skills - skilled in Microsoft Office applications and others as required
• Project management - administers using tools and processes to identify and communicate project goals, schedules, responsibilities, progress and performance
• Teambuilding - demonstrates ability to foster and perform in a team-building environment