Manager Quality Safety and Risk Management

Job Summary

The Manager Quality, Safety and Risk Management is responsible for the system’s risk management activities which include risk management and patient safety program administration; event management; licensure, regulatory, and accreditation compliance; and hospital and medical staff education. The Manager is responsible and accountable to ensure that the Department Goals and Objectives are aligned with the Corporate Objectives and Strategic Plan.

Essential Functions

• Understands system and business practice concepts and work approaches used to systematically pursue ever-higher levels of performance.
• Understands or demonstrates understanding of strategic planning, research, and development and analysis processes that do not normally imply formal sequences of steps.
• Ensures new ideas are adopted and implemented to continually support the Healthcare mission while successfully accomplishing those goals the organization must attain for its strategy to succeed.
• Ensures employees share knowledge, understand decisions and the reasons why decisions are made and implemented.
• Functions as a resource and internal consultant to key contact personnel regarding Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) and the Office of Inspector General (OIG).
• Aids Executive team members and Department Directors in designing risk management programs and processes which meet regulations and standards while mitigating risk to the system.
• Oversees investigation of all incidents, events, and accidents that are potentially compensable or that could result in a claim. Completes Root Cause Analyses (RCAs) when indicated, implementing necessary action plans.
• Makes sure compliance with RCA action plans is monitored.
• Gathers adverse event data, analyzes data, and prepares risk management reports related to adverse events. Informs leadership of major occurrences, issues, findings offering suggestions and recommendations regarding opportunities for risk mitigation and patient safety.
• Aids Executive team members and Department Directors with the development and implementation of action plans or Evidence of Compliance reports which address Department of Health (DoH) or CMS deficiencies and Joint Commission recommendations. Monitors compliance with established plans.
• Plans and implements education/training plans addressing risk management, patient safety, and regulatory and accreditation compliance considering client needs and system constraints.
• Considers and incorporates efficiency and cost containment measures into recommendations, projects, and processes.
• Develops working relationships with regulatory agencies.

Required Additional Requirements

• Certification - Registered Nurse (RN) - South Dakota Board of Nursing
• Preferred Experience - 1+ years of Quality Assurance/Improvement Experience; 3+ years of Clinical Experience
• Education - Bachelors degree in Related Field

Physical Requirements

Sedentary work - Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

Job Category

Quality Risk Management and Compliance

Job Family

Quality Review

Shift

Requires the ability to work assigned schedules and hours as determined by the department