Oversees all Risk Management activities including managing claims against the facility; interfacing with defense counsel; interacting with patients, medical staff and hospital staff to resolve complaints; administering the risk management program on a day to day basis; managing and analyzing the risk management data; overseeing the patientsafetyprogramsinordertomaintainanenvironment thatoptimizespatientsafetyandreducesthelikelihood of medical/health errors. Oversees all quality management activities including: performance improvement, quality review, TJC readiness, core measures management. Plans, implements, evaluates and reports on all quality functionsthroughouttheorganization.Participatesinhospitalandmedicalstaffcommitteesasrequired.Establishes policies and procedures as needed. Performs ongoing TJC preparedness reviews of the hospital, including national patient safety goals. Responsible for day-to-day management of the Hospital's participation with LifePoint PSOrg, LLC, including collecting patient safety information and reporting it to LifePoint PSOrg, LLC on an ongoing basis for analysis and feedback. Ensures patient safety work product is appropriately labeled and submitted to the patient safety evaluation system and reported to the LifePoint PSOrg as appropriate.

ESSENTIALFUNCTIONS

Providescoordinationanddirectionofthehospital’sQualityandRiskManagement,PatientSafetyandCompliance Program through maintenance and improvement in issues in every department throughout the hospital.

Demonstratesaconsistentlywell-organizedapproachtoalldutiesandactivitiesassignedbytheCEO.

Investigatesandprovidesdocumentationonallcomplianceissuesandhotlinecallsandcollectsandsubmits Compliance Dashboard quarterly

EvaluatestheRiskManagementandPatientSafetyProgramsannually,takingactionontrendsnotedandreports results to the BOT.

Servesasliaisontoinsurancecompaniesandlegalcounsel.ManageslegalclaimsagainstthehospitalandMarion Clinic. Maintains all legal case files and ensures maximum protection from discoverability of all such files.

Collectsandreviewsdatatoidentifytrendsregardingoccurrencesandprovidesaggregationofanalysisofdata.

Reportsto:CEO