General Summary of Duties: Coordinates QI/Risk Management programs for a surgical facility. Responsible for promoting safe and efficient work environments for all staff members. Coordinates market and/or facility wide programs for the continuous improvement of the quality of care and service delivered to all customers - patients, physicians, employees and payors. Assist with providing patient care support as needed.
SUPERVISOR – Center Administrator
CLASSIFICATION - Exempt
SUPERVISES - None
OPERATIONAL DUTIES INCLUDE BUT ARE NOT LIMITED TO:
Oversees the collection, compilation, analysis and presentation of evidence based measure data as assigned.
Prepares and presents requested reports regarding findings and outcomes of measures.
Assists with implementation of Best Practices program.
Maintains and generates monthly best practice reports.
Distributes Service Quality Index scores appropriately.
Facilitates a team-oriented approach to process improvement and problem solving.
Assist team leaders in scheduling of meetings and act as facilitator for meetings when needed.
Provide periodic reporting of process improvement activities/QI studies to QI Committee, Medical Executive Committee (MEC) and Governing Board (GB) generally on a quarterly bases and upon request.
Develops and manages Peer Review process.
Oversees safety in-services/program, including fire drills, disaster drills, including mock codes, Malignant Hyperthermia drills.
Performs monthly tracking and trending of patient satisfaction survey feedback and reporting to QI committee. Coordinates implementation of corrective actions as required.
Assist in maintenance of requirements from OSHA, CMS, AAAHC, and federal agencies related to quality improvement, risk management, and quality of care.
Locates and organizes all service contracts and tracks renewal and compliance.
Maintains documentation of preventative maintenance activities.
Initiates annual review of policy and procedure manuals.
Submits new/revised policies and procedures to QI Committee, MEC, and GB for approval.
Coordinates preparation for State/Federal inspections and accreditation surveys.
Promotes focus on customer satisfaction with all employees and management staff.
Adheres to concepts of continuous quality improvement at all times and encourages all staff to utilize the tools learned in local training sessions.
Schedules training sessions in continuous quality improvement for new employees.
Maintains and implements a variance reporting system for the center.
Receives and reviews all variances generated by personnel at the center.
Investigates and analyzes all variances; actual and potential risks at the center.
Follows up on all variances until situation is resolved.
Reports significant variances until situation is resolved.
Follows up and maintains appropriate reporting and documentation of employee exposures to blood borne pathogens.
Takes steps to ascertain that risks are minimized through follow-up and actions on all regulatory/insurance survey report recommendations/deficiencies.
Functions as the center’s Infection Control Nurse, if required.
Coordinates distribution of Infection Control/Complication queries to all surgeons on a monthly basis. Track and trend return of responses and report to QI Committee, MEC, and GB on a quarterly basis.
Follows up report of any infections/complication to Administrator/Medical Director as appropriate.
Reviews pathology reports monthly. Maintains pathology reports and summarizes for QI Committee, MEC, and GB quarterly.
Audits and reports variance patterns and trends to Quality Improvement Committee, MEC, and GB to identify actions to be taken.
Prepares reports and summaries on all risk management findings on a quarterly basis to the Quality Improvement Committee, MEC, and GB.
Communicates relevant risk management findings with Administrator, Center Managers, and Medical Director on an ongoing basis.
Provides risk management education to staff per state and accrediting agencies requirements and when needed.
Notifies center’s claims representative of all actual and potential claims, and ensures PCR’s are completed, when necessary.
Functions as a liaison with the claims representative and attorneys; and provides information as required for the management of cases.
Maintains risk management and legal files in a confidential and appropriate manner.
Coordinates actions relating to reports of product problems (e.g., drug devices, equipment, and food recalls).
Assists with managing the Workers Compensation program in coordination with Human Resources.
Conducts or delegates responsibility to conduct facility safety audit on a quarterly basis.
Evaluates patient and/or family complaints/grievances in conjunction with Administrator/Center’s Managers and assesses risk to center and ensures appropriate responses, per center’s policy and procedure.
Coordinates and oversees center compliance with Safe Medical Device reporting and tracking.
Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”
Other duties as assigned
KNOWLEDGE, SKILLS & ABILITIES
Organization - proactively prioritizes needs and effectively manages resources
Knowledge of operating room/PACU/Pre-operative standards/techniques.
Ability to instruct and manage personnel, both professional and non-professional.
Ability to gather and analyze data and prepare management reports.
Ability to speak clearly and distinctly.
Takes initiative and exercises good judgment.
Maintains high level of confidentiality at all times.
Adaptability -Alertness and adaptability to change in situation.
Communication - communicates clearly and concisely. Must be able to communicate effectively with patients and their family members, physicians, co-workers and center management.
Leadership - guides individuals and groups toward desired outcomes, setting high performance standards and delivering leading quality services
Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
Tactical execution - oversees the development, deployment and direction of complex programs and processes
PC skills - skilled in Microsoft Office applications and others as required
Project management - administers using tools and processes to identify and communicate project goals, schedules, responsibilities, progress and performance
Teambuilding - demonstrates ability to foster and perform in a team-building environment
Welcome to Reston Surgery Center located in Reston, Virginia. We are an ambulatory surgery center specializing in same-day surgical procedures providing the opportunity for patients to recover in the comfort of their own home instead of the traditional hospital setting. We are proud to provide these services to the residents of our city, Fairfax county and the surrounding communities in our area.
Reston Surgery Center is a leading healthcare provider in Reston since 2004. Located at 1860 Town Center Drive, Suite G100 in the Parkway Medical Tower Building on the campus of Reston Hospital Center. Our state-of-the-art facility accommodates 6 large surgical suites, and specialty procedure rooms for pain management and minor procedures.
Over 140 surgeons, perform a broad range of surgical procedures in a private setting. We are proud that our staff of over 70 employees upholds a tradition of providing quality healthcare services in a professional and caring environment.