JOB TITLE: Manager, Risk & QI
RN strongly preferred
Qualified candidates should hold a degree in nursing or public health, health admin, public policy preferred, RN strongly preferred, (or other clinical) and training in risk management, Quality Improvement, and/or CPPS (certified professional in-patient safety) helpful.
Minimum of 5 years in a health center, required health care, ambulatory care, or risk management field. Experience with incident reporting, risk management, auditing clinical practice, leading program change/ transformation, training staff, knowledge of EHRs and conducting root cause analyses (RCA) and/or failure mode and effects analysis (FMEA) desired or equivalent combination.
Interested candidates should apply thru Indeed & directly to Duffy Health Center @ Careers – Duffy Health (duffyhealthcenter.org)
Statement of Duties-Duffy Health Center is a patient-centered medical home, and every role requires functioning effectively using a team-based approach. The Manager of Risk and QI is a member of the Management Team at Duffy Health Center. The position is responsible for monitoring organizational systems to ensure effective health center wide quality improvement, risk management, and patient safety. The incumbent serves as the Health Center’s Risk Manager. This position is deemed essential* in the DHC Emergency Operations Plan.
Position functions The statements contained in this job description reflect general details, as necessary, to describe the principal functions of this job, the level of knowledge and skill typically required, and the scope of responsibility. It should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties, as assigned, including work in other functional areas to cover absences or provide relief, to equalize peak work periods or otherwise to balance the workload.
1. Responsible for coordinating the patient care risk management program to meet the needs of Duffy Health Center, including investigating, managing, and analyzing risk management activities and data (grievances reports, incident reports, other data).
2. Understands and assesses compliance with risk management standards (HRSA, HIPAA, FTCA, etc.), organizes and conducts or arranges risk management training to meet FTCA risk management requirements and other types of mandatory risk management training and creates the annual risk management training plan with the Chief Compliance Officer insuring input from managers.
3. Oversees and manages the automated incident reporting system, database, and tracks trends of incidents by category. Learns, trains others, and assists with implementation of, and maintains automated incident reporting software system in development currently. Acts as a resource person to staff for incident reporting. Investigates and summarizes incidents, including talking with patients as needed. Leads any necessary RCAs and debriefings. Determines any needs (with CMO) for focused reviews.
4. Coordinates investigating and reporting with respect to serious reporting events in conjunction with Chief Medical Officer, Director of Nursing and Clinical Operations or Director of Behavioral Health and other near misses and adverse events.
5. Under the direction of the CMO and Associate Director of Compliance/CCO) supports quality
improvement efforts at the Health Center including preparing PIC reports and assisting with meeting preparation, agenda, minutes, and invitations. Works to update and implement aspects of the Duffy’s ACO (C3) quality workplan. Stays abreast of varying population health awareness months and prepares messaging and QI communications to all staff in support of these efforts. Works with the Data Analyst and prepares the quarterly QI Board report presented first at PIC and then at the Board.
6. Coordinates the organization’s administration of patient satisfaction surveys and as needed revamps questions, sends out surveys, and reviews and analyzes results with the Data Analyst. Prepares presentation of patient satisfaction results. Monitors and responds to comment box submissions by patients.
7. Stays abreast of QI tools and shares these with departments. As needed provides just in time coaching of staff on how to use various QI tools (RCA, debriefing, PDSA, FMEA, etc.)
8. Under the direction of the CMO and Associate Director of Compliance/CCO conducts various QI projects each year that supports our maintenance of PCMH status including one project each with a) OBAT – implementation of care plans, b) BH – ED/Inpatient follow-up measures, c) Psych – Epic documentation, and d) SUD – Epic documentation to meet policy requirements. Undertakes process improvement projects such as diabetes care improvement.
9. Supports the Director of Nursing and Clinical Operations with occupational health annual occupational vaccination screenings and tracking of flu and COVID vaccinations as well as annual N95 FIT testing. Assists with organizing the staff vaccination clinics and tracking compliance. Assists the DNCO with follow-up on the annual infection control audit and monitors adherence to corrective actions. Performs periodic audit of various clinical processes to ensure risk avoidance, such as annual medical inspection audit, refrigerator and med cabinets checks, etc.
10. Supports the DNCO during Medical Response Team (MRT) drills.
11. Provides routine updates at PIC meetings on incident reports and status of follow-up. Prepares and analyzes trend analysis and preparation of reports, dashboards, and presentation for various audiences – at department meetings, MT, full staff, PIC, Compliance Committee, or Board. Presents relevant risk management issues for discussion, evaluation, or presentation at MT or full staff meetings as appropriate.
12. Organizes and participates in Safety Walk Rounds with CEO and other LT members especially focusing on ways to enhance patient safety. Includes data from the Walk Rounds as part of the annual report of risk management activities for Leadership Team and the Board of Directors.
13. Facilitates completion of safety solutions with appropriate management staff for identified issues.
14. With CCO prepares quarterly risk management plan updates and works with staff to assist with completion of tasks in support of achieving the goals of the annual risk management plan, including organizing workflow improvement teams if needed.
15. Conducts risk assessments to inform the development of annual risk management goals in the RM Plan especially with respect to patient care areas. Risk assessments include numerous methods: facility rounding, safety walk rounds, review of prior year minutes for key committee (PIC, EOC, Compliance, MT, and Workplace Safety) and infection control audit to identify elements for inclusion in RM work plan. Identifies organizational risk through trend analysis of incidents, patient grievances, Safety WalkRounds, using checklists, and review of audits.
16. Conducts chart audits and assists with FPPE under the guidance of CCO or CMO to assess for any potential risk areas.
17. Under oversight by Director of Compliance and Operations Improvement prepares annual FTCA application to HRSA. Works with constituents (HR and department managers as needed) throughout the year to ensure that the necessary components are ready for credentialing and privileging requirements and the risk management training documentation. Submits annual incident reporting information to ECRI PSO. Prepares annual report of data (QI, incidents, focused reviews, etc.) for submission annually to the Board of Registration in Medicine.
18. Assists Associate Director of Compliance/CCO with compliance activities including but not limited to maintenance of clinical compliance tracking, policy development and updating, ongoing assessment of HRSA Operational Site Visit readiness, contract management. With Associate Director of Compliance/CCO and CMO supports CEO in any claims management needs. Serves as back-up to CCO for risk management functions.
19. Assists in developing educational programs to raise staff awareness to risk exposure and the impact on professional liabilit
15. Other duties as required.
Minimum Education and Experience
Degree in nursing or public health, health admin, public policy preferred, RN preferred, (or other clinical) and training in risk management, Quality Improvement, and/or CPPS (certified professional in patient safety) helpful.
Minimum of 5 years in a health center, required health care, ambulatory care, or risk management field. Experience with incident reporting, risk management, auditing clinical practice, leading program change/ transformation, training staff, knowledge of EHRs and conducting root cause analyses (RCA) and/or failure mode and effects analysis (FMEA) desired or equivalent combination.
Requirements under the DHC Emergency Operations Plan
During a declared Emergency, staff deemed as Essential Personnel are expected to work onsite at
Duffy Health Center and Non-Essential Personnel are expected to work remotely. This position is
Essential and will work on-site to provide direct clinical care or management of such.
Knowledge, Skills, and Abilities
A candidate for this position should have the following:
Must be comfortable making and giving presentations to all levels of staff. Ability to learn, understand and document workflows of the organizations. Familiarity and usage of EHRs. Ability to lead debriefings, root cause analyses, and other QI techniques.
Knowledge of:
- Primary care and behavioral health services in organizations serving vulnerable and marginalized populations, with community health center experience a plus
- incidents/risk management or quality/operations issues
- Electronic health record systems
Skill in:
- Excellent project management skills, a certification in project management is a plus.
- Preparing and delivering presentations to all levels from the Board to front line staff
- Computer use and Windows software
- Protocols for handling emergency/crisis situations
And ability to:
- Communicate effectively and persuasively at all levels of the agency
- Function as a leader without direct line management authority
- Influence others up, down and across the organization’s hierarchy
- Learn, understand and document workflows of the organization
- Lead debriefings, root cause analyses, and other QI techniques
- Collaborate in work to support both front line staff and management and leadership teams
- Commit to the philosophy and mission of Duffy Health Center which serves the homeless and at-risk population, and to the team-based approach as part of PCMH
Accountability
Consequences of errors, missed deadlines, or poor judgment, could have a continuing adverse effect on business functions and /or regulatory or legal repercussions.
Judgment
The work requires examining, analyzing, and evaluating facts and circumstances surrounding individual problems or situations and determining actions to be take within the limits of standard or accepted practices. Guidelines include a large body of policies, practices and precedents which may be complex or conflicting, at times. Judgment is used in analyzing specific situations to determine appropriate actions. Requires understanding, interpreting and applying complex financial medical, dental or behavioral health research as well as federal, state and local regulations.
Complexity
The work consists of employing many different concepts, theories, principles, techniques and practices relating to the health care field. Assignments typically concern such matters as studying trends in the field for application to the work, assessing services and recommending improvements planning long-range projects, devising new techniques for application to the work, recommending policies, standards or criteria.
Supervision Required
Under general direction, the employee plans and carries out the regular work in accordance with standard practices and previous training, with substantial responsibility for determining the sequence and timing of action and substantial independence in planning and organizing the work activities, including determining the work methods. The employee is expected to solve through experienced judgment most problems of detail or unusual situations by adapting methods or interpreting instructions to resolve the particular problem. Instructions for new assignments or special projects usually consist of statements of desired objectives, deadlines, and priorities.
Technical and policy problems or changes in procedures are discussed with supervisor, but ordinarily the employee plans the work, lays it out and carries it thorough to completion independently. Work is generally reviewed only for technical adequacy, appropriateness of actions or decision and conformance with policy or other requirements; the methods used in arriving at the end result are not usually reviewed in detail.
Nature and Purpose of Contacts
Relationships with co-workers and the general patient population involving frequent explanation, discussion or interpretation of practices, procedures, regulation or guidelines in order to render service, plan or coordinate work efforts or resolve operating problems. Other regular contacts are with patient/service recipients and employees of outside organizations. More than ordinary courtesy, tact and diplomacy may be required to resolve complaints or deal with hostile, uncooperative or uninformed persons.
Work Environment
The work environment involves everyday discomforts typical of offices, with occasional exposure to outside elements. Noise or physical surroundings may be distracting, but conditions are generally not unpleasant.
Physical Demands
Little or no physical demands are required to perform the work. Work effort principally involves sitting to perform work tasks, with intermittent periods of stooping, walking, and standing.
There may also be some occasional lifting of objects (up to 10lbs.).
Motor Skills
Duties are largely mental rather than physical, but the job may occasionally require minimal motor skills for activities such as moving objects, computer and/or most other office equipment, typing, filing or sorting, operating basic medical equipment, or operating a motor vehicle.
Occupational Risk
Duties generally do not present occupational risk with only occasional exposure to risk or stress.
Minor injury could occur, however, through employee failure to property follow safety precautions or procedures. Examples of injury include minor bruises from falls, minor cuts or burns, or minor muscular strains from lifting or carrying equipment or materials.
Confidentiality
Has regular access at the departmental level to a wide variety of confidential information, including personnel records, medical records of employees or patients, client records, criminal investigations, court records, financial records.
Duffy Health Center is committed to creating and maintaining a diverse workforce. We actively encourage applicants from minority racial and ethnic backgrounds, as well as historically marginalized groups. This includes but is not limited to LGBTQ persons and people with lived experiences of homelessness or recovery.
Duffy Health Center offers 2 bonus opportunities in the first year of employment. $500 after your 6 month work anniversary. $1000 after your one year work anniversary.
Job Type: Full-time
Pay: $75,000.00 - $95,000.00 per year
Benefits:
- Dental insurance
- Employee assistance program
- Family leave
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Loan repayment program
- Mileage reimbursement
- Paid time off
- Parental leave
- Referral program
- Retirement plan
- Tuition reimbursement
- Vision insurance
Medical Specialty:
Schedule:
- 8 hour shift
- Monday to Friday
Application Question(s):
- Are you now of have you been a patient at Duffy Health Center in the last 2 years?
- Do you hold a current RN license in Massachusetts?
Work Location: In person
