CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner. HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous research centers in the U.S. and Korea including a medical university, and CHAUM (a premier anti-aging life center)

Job Summary Responsible to review and track incident reports ensuring that follow-ups are complete; analyses incident reports to evaluate event severity and identify potential system /process deficits via exercising critical thinking skills and/or clinical judgment; perform investigations under the direction of the Vice President of Quality & Risk Management; prepare reports of sentinel events resulting in liability exposure; act as resource person for all Hollywood Presbyterian Medical Center (HPMC) employees concerning risk management issues; Performs information management functions of data abstraction. Utilizes continuous quality improvement tools and methodologies to assure data integrity of the PI and Risk Management related data bases. Responsible for interfacing external sources, in addition to supporting HPMC’s efforts to identify, measure, assess, and improve patient care, quality and safety. Responsible for coordinating and assisting the VP of Quality & Risk Manamgent with Risk Management and Compliance related programs with the objective of controlling and minimizing loss to protect the human, physical, and fiscal assets of the organization. Assists with functions that promote an integrated program to ensure the provision of the highest quality of health care. Performs other duties as needed.

· Coordinates and supports the administration of the risk management and compliance program.

· Develops and implements appropriate measures to identify and minimize the risk of injury to patients, visitors and staff, and to minimize loss or damage to property.

· Identifies, at the earliest opportunity, any evidence/scientific-based changes, or proposals that may impact the organization and make recommendations of how compliance can be achieved.

· Coordinates and assures efficient and effective occurrence review and claim file management.

· Prepares and timely submits monthly, quarterly and annual reports as required.

· Takes appropriate action, and follows through, based on review of incident reports, legal case investigation, and hospital-wide risk/compliance-related aggregated data.

· Assists with the Environment of Care program to ensure regulatory compliance under the direction of the VP of Quality & Risk Management.

· Coordinates the implementation of the Risk Management Plan.

· Responsible for investigating adverse patient outcomes and near misses, analyzing events, formulating safety plans, participating in policy review, claims investigations, and assisting with responses to regulatory agencies.

· Consults with staff, leadership, physicians, risk management consultants, legal teams, and other teams to ensure application of best practice procedures, policy alignment, and our compliance with rules and regulations in order to reduce risk for patient harm.

· Facilitates Root Cause Analysis (RCA’s) and prepares case summaries, timelines, with the goal of identifying proactive risk reduction opportunities to improve patient care and mitigate legal risks.

· Facilitates hospital-wide Failure Mode and Effects Analysis (FMEA) to identify and address potential problems or failures and their resulting effects on the system or processes.

· Represents the Risk Management Team in various meetings. Regularly attend and actively participate in the facility’s Quality Committee, EOC and other Committees as assigned.

· Interacts with appropriate and positive customer service with peers, staff, physicians and patients.

· Maintains confidentiality of information.

· Ensures accuracy and consistency in data collection.

· Exhibits flexibility to learn new areas, expanding professional and technical skills.

· Contributes to staff and physician orientation to Risk Management.

· Assists in achieving identified clinical and quality outcomes. Works collaboratively with a proactive management team to set business and quality goals that are realistic and meaningful and result in quantifiable improvement.

· Provides support to outside counsel and claims administrator on litigated matters, including but not limited to timely witness scheduling, locating related policies and records, and other investigation as directed by counsel. May participate at mediations as needed.

· Assists with special projects, committees, and performance improvement activities for the improvement of the organization. Provides meeting support, e.g., ensure meetings are scheduled and designated individuals invited, prepares agendas, records/distributes/archives minutes, ensure follow-up on action items when needed.

· Provides oversight to projects including data abstracting and data entry as appropriate.

· Leads the collection and organization of data for assigned committee presentations.

· Assists with preparation of monthly, quarterly, and annual reports as required

· Assists with activities for online event reporting and serve as back-up as directed

· Assist with and assumes other duties as required.

Minimum Education

• Bachelor’s degree from an accredited four-year college or university, preferred in healthcare-related field

Preferred Education

• Master’s degree from an accredited college or university, preferred in healthcare-related field

Minimum Work Experience and Qualifications

· Registered Nurse, other clinical professional or minimum of four years’ experience in a healthcare related field, performing data analysis.

· Previous experience in Risk Management

· Ability to present, explain data and trends to various levels of key stakeholders.

· Ability to communicate effectively verbally and in writing.

· Must be able to work in a union environment.

Preferred Work Experience and Qualifications

· Project management.

· Leadership skills

· Ability to manage multiple projects with competing priorities.

· Knowledge of CMS, Title 22, Joint Commission, Federal and State healthcare compliance program requirements and Cal OSHA law and regulations

Required Licensure, Certification, Registration or Designation

· Current Los Angeles County Fire Card required (within 30 days of employment).