Risk Manager - Quality Management

In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Preference is given to applicants who are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe, legally married to enrolled members of these tribes and meet residency requirements, or enrolled members of other federally-recognized American Indian Tribes.

About the role

This position is located within the Quality division at Tuba City Regional Health Care (TCRHCC). The incumbent is responsible for the management, development, administration, education of staff, and documentation of all risk management and issues for TCRHCC, including all external extensions of the hospital. Compliance with risk management standards is required for TCRHCC accreditation by The Joint Commission (TJC), as well as other federal, state, and tribal regulations. Data generated through this program supports hospital-wide policy development and identifies trends and issues for further study, improvements, or corrective action.

Responsibilities

• Manage, develop, administer, evaluate, and document the risk management program for TCRHCC.
• Prepare the risk management program plan, yearly evaluation of program effectiveness, and trend and analyze risk management data. Provide an annual report to the Senior Leadership Committee (SLC), Performance Improvement Committee (PIC), and Board of Directors (BOD).
• Orient and educate TCRHCC staff on risk management procedures, techniques, and regulations. Collaborate with the Patient Safety Officer to train and assist staff with the occurrence reporting system, track issues, analyze, and refer them for resolution.
• Review daily House Supervisor’s reports for key identified risk issues; attend daily Safety Huddles.
• Track and review incident reports relating to patient safety in collaboration with the Patient Safety Officer. Investigate verbal or written reports containing actual, questionable, or potential risk management issues.
• Serve as a member of the Performance Improvement Committee (PIC) and Safety Committee; identify facility-wide issues and recommend appropriate action to the PIC, Chief Quality Officer, and/or Chief Executive Officer (CEO).
• Perform chart reviews of patient records to gather, analyze, and trend data; make recommendations to the PIC.
• Identify, track, and document all Potentially Compensable Events (PCE) in the facility. Obtain Peer Review or other reviews when appropriate and ensure corrective action is taken.
• Research and assess allegations of unacceptable patient care; provide recommended solutions, implementation monitoring, and follow-up.
• Identify Sentinel Events and coordinate Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), as appropriate; provide reports to relevant staff in collaboration with the Chief Quality Officer.
• Collaborate with the Chief Compliance Officer and Chief Quality Officer to coordinate and track all tort claims; maintain tort files securely. Notify and work with providers named in a tort claim.
• Coordinate malpractice subpoenas received for TCRHCC; work with legal counsel to ensure strict adherence to correct processes. Coordinate depositions and interviews, including arrangements for room reservations, scheduling, document presentation, and record maintenance.
• Consult with legal counsel in the formulation and review of TCRHCC policies and procedures that impact facility liability or risk control.
• Develop proactive responses to patients, their families, and employees following investigations of potentially compensable events and asserted legal actions.
• Coordinate with Clinical Staff for electronic health records data entry pertinent to patient services or interventions related to risk management issues.
• Perform other duties as assigned.

Requirements

• Bachelor of Science in Nursing.
• Valid, current, full, and unrestricted Professional Nursing License to practice nursing in any U.S. state, the Commonwealth of Puerto Rico, or a U.S. territory.
• Experience in a healthcare setting with a focus on directing and implementing major processes related to performance improvement, risk management, patient safety, process improvements, and effective communications.

Skills

• Ability to provide in-depth reports to diverse audiences succinctly and timely.
• Knowledge of TCRHCC mission, healthcare agencies, hospital self-assessment programs, TJC accreditation requirements (including performance improvement, risk management, infection control, safety, patient safety, and utilization review), and National Patient Safety Goals.
• Knowledge of the Privacy Act, Health Insurance Portability and Accountability Act (HIPAA), safety, security, claims investigation, patient advocacy/ombudsman policies, and procedures.
• Strong writing, interpersonal communication, organizational, and computer skills.
• High ethical standards with no history of complaints; reliable and dependable with consistent attendance.
• Positive working relationships with others.
• Successful completion of background checks, reference checks, fingerprint clearance, physical examinations, and other screenings demonstrating the ability to perform essential job functions.
• Submission of all required employment-related documents free of false, misleading, or incomplete information.

Mental and Physical Effort

Physical: The incumbent must be able to sit, stand, walk, drive, crouch, twist, maintain balance, and reach for prolonged periods (greater than 3/4 of the workday). Must frequently (1/2 workday) climb, kneel, and bend. Ability to lift, push, and pull up to 100 pounds occasionally, and frequently lift up to 10 lbs and push/pull up to 25 lbs. Must have far vision, near vision, color vision, depth perception, and the ability to see fine details. Must be able to hear normal speech, use a telephone, and hear overhead pages through a loudspeaker for prolonged periods (3/4 workday). Ability for simple grasping, firm grasping, fine manipulation, and keyboard use for prolonged periods (3/4 workday). The position is mostly sedentary but requires frequent standing, walking, and bending for presentations and investigations.

Mental: The incumbent must have the mental and emotional ability to cope with high levels of stress, make decisions under pressure, concentrate, handle flexibility, manage multiple priorities in stressful situations, work alone, demonstrate patience, and work in close, crowded areas. Must frequently manage anger, fear, or hostility of others calmly and handle altercations. Occasionally may need to adapt to shift work.

Environmental: The incumbent may be frequently exposed (1/2 workday) to infectious diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.