Position Description

Commonwealth of Pennsylvania
POSITION DESCRIPTION FOR JOB POSTING
Position Number: 00085214	Description Activated On: 12/19/2025 1:36:53 PM

Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively.

The employee occupying this position is responsible and accountable for the development, integration, and coordination of the hospital-wide Performance Improvement, Risk Management, Abstracting, and Infection Control Programs in order to maintain the Hospital’s certification. The employee is responsible and accountable for the supervision of the Department of Performance Improvement. This department directs and monitors all Performance Improvement, Risk Management, Medical Records, Abstracting, and Infection Control activities for the hospital. The employee works under the supervision of the Hospital Chief Executive Officer.

Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor.

Reviews all compliance standards and requirements and assesses status of the Hospital in relation to standards by identifying deficiencies and clinical or administrative problem areas impacting the quality of patient care and treatment in order to assure the Hospital’s compliance with standards and regulations, promulgated by Medicare, Medical Assistance, Department of Human Services,Department of Health, CMS and all certification agencies. Develops and institutes new hospital initiatives in response to new standards through policy/procedure development, development of patient and staff educational materials and programs, and monitoring of actions/improvements to ensure appropriate response, compliance, and utilization of resources.

Provides oversight for the Hospital-wide Risk Management Program which involves the following activities: reviewing all patient incident reports; ensures input of all reports into the Risk Management computerized database system; tabulates statistical data and reports trends and/or benchmarks/comparisons to appropriate Hospital committees and departments; ensures facility inspections to identify potential risk areas are scheduled and corrective actions taken; conducts a root cause analysis into all sentinel events and near miss errors/incidents; conducts training to all new employees on proper reporting of incidents; develops programs in order to involve staff and patients in the identification, prevention, and reduction of risk areas and occurrences of incident. Facilitates the coordination and preparedness of all regulatory agency visits to the hospital.

Serves as the chairperson for the hospital-wide quality committee. Collects hospital-wide data on quality indicators and facilitates plans for improvement during the hospital-wide quality committee monthly meeting.

Collects, analyzes, and disseminates incident data (patient and employee) for the benchmarking projects for hospital information needs, and to effect improvement efforts as deemed necessary.

Develops, implements, and monitors follow-up action on any internal or external survey deficiencies by preparing a plan of corrective action with the appropriate person(s) responsible for the deficiency in order to assure all deficiencies are corrected within the established target date. Prepares and submits applicable reports as required.

Plans, organizes, and directs work and implementations of the Performance Improvement Program by developing/chairing/consulting on IOP activities, developing goals, prioritization of projects, and assigning, reviewing, and evaluating subordinates’ work efforts in order to assure Hospital compliance with the Performance Improvement Program.

Plans, organizes, and directs work and implementations of the Medical Record Program by developing goals, prioritization of projects, monitoring of policies and procedures, and assigning, reviewing, and evaluating subordinates’ work efforts in order to assure Hospital compliance with all applicable accreditation/certification agency requirements and standards. Serves as the primary facility contact for HIPAA in order to ensure ongoing compliance with the federal standards.

Plans, organizes, and directs work and implementations of the Infection Control Program by developing goals, prioritization of projects, monitoring of policies and procedures, and assigning, reviewing, and evaluating subordinates’ work efforts in order to assure Hospital compliance with all accreditation/certification agency requirements and standards.

Assists in the development, revision, and review of all applicable hospital policies/procedures by chairing the hospital-wide Policy/Procedure Committee and by applying current literature/reference changes in order to meet standards and ensure compliance with all certification agency requirements.

Assist in the provision of applicable inservice training to staff on Performance Improvement/Risk Management/Information Management issues/ procedures by developing a training plan, securing input, and actual lecture, in order to maintain staff awareness and understanding of Performance Improvement/Risk Management/Information Management procedures.

Coordinates the gathering, inputting, and dissemination of People Stat data.

Continuously examines and monitors the Hospital’s Medical Record’s policies and procedures, with specific respect to clinical assessments, treatment plans, and special treatment procedures, by conducting medical records audits in order to identify deficiencies and/or trends and develop corrective actions to maintain compliance with all accreditation/certification agency standards.

Collects and prepares data on potential risk trends by reviewing all incident reports and through representation on the Hospital’s Executive Staff in order to provide an effective Risk Management analysis tool for management.

Serves as the hospital’s Administrative Investigation Coordinator. Receives reports of alleged patient abuse and miscellaneous administrative violations and coordinates and conducts actual investigations by interviewing all involved parties, receiving statements, collecting data, and compiling a comprehensive report, in a timely manner, for the CEO’s review in order to assure the protection of patient and employee rights and to meet all hospital and DHS standards and policies. Also, to participate in ongoing training related to abuse investigation techniques in order to assure compliance with existing standards.

Serves as the hospital’s legal liaison for the purposes of criminal proceedings for patients, legal actions against the hospital, and processing of Pennsylvania State Police criminal record checks for all patients. In this capacity, ensures Performance Improvement staff attendance at legal proceedings with patients, provides communication with the appropriate judicial representatives, prepares reports and communications on behalf of the CEO and the hospital, interfaces with all involved constituents, works closely with hospital attorneys on preparing witnesses for depositions and written briefs, maintains statistical data and logs of criminal record checks and disseminates information to required departments/individuals.

Holds membership and attends meetings of assigned hospital committees including Collaborative Practice, Infection Control, Information Management, Pharmacy and Therapeutics, Utilization Review, Quality Committee, and Human Rights. Develops task forces and ad hoc committees to survey, assess, and develop resolutions to specific issues and concerns. Reviews minutes of all standing Hospital committees and staff meetings.

Advises staff on records management issues by serving as Records Manager for the Hospital in order to assure proper inventory, classification, disposition of inactive records, and maintenance of active hospital records.

Represents the CEO by attending meetings or functions, public appearances, media interviews, and general activities or briefings in order to assure hospital policy is stated and understood and in order to assure full communication between the CEO’s office and others.

Serves as the hospital’s Official-in-Charge and Administrator On-Call in the absence of the Chief Executive Officer. Receives all administrative and clinical issues/problems during and after routine working hours, determines the appropriate course of action, and initiates actions in response to the specific issue(s). On-call duties require this employee to be readily available during the specified time period.

Serves on statewide committees, task groups, and staff meetings as requested or assigned in order to represent the hospital and OMHSAS and apply current certification standards.

Performs other related duties and special projects as assigned. The purpose and standards will be given at the time of each assignment.

ADA STATEMENTS

Required Knowledge, Skills, and Abilities:

Knowledge of facility administration and its interrelated systems.

Knowledge of principles and practices of healthcare administration.

Ability to plan, organize, and direct the development of the facility’s performance improvement.

Ability to analyze and evaluate clinical and non-clinical practices, resource planning and development, and healthcare organizational issues/data in order to recommend and develop operational and monitoring procedures for improved service delivery or problem resolution.

Essential Employee

Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature.

As outlined in the above Job Duties/Responsibilities.

Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License

Experience:

Licenses, registrations, or certifications:

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2.   N/A

3.   N/A

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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.

1.	Ability to express ideas clearly and concisely, orally and in writing, and to speak effectively in public.
2.	Ability to read and interpret collective bargaining contractural agreements applicable to work performed in the unit.
3.	Ability to prepare and present findings and to provide support and guidance concerning needed corrective actions.
4.	Ability to understand and apply research and evaluation methodologies and automated data collection and retrieval systems applications to performance
5.	Ability to establish and maintain effective working relationships with professional and technical staff, the general public, and others.
6.	Ability to provide leadership and technical assistance to clinical and non-clinical staff on such regulatory requirements as: Medicare, Medicaid, and
7.	Ability to plan, organize, direct, and evaluate the work of interdisciplinary clinical professional staff and non-clinical support staff.
8.	Ability to integrate a comprehensive performance improvement/risk management operating structure into a hospitalwide system.
9.	Knowledge of the principles, practices, and methods of program planning, organization, and direction relative to performance improvement and risk mana
10.	Knowledge of DHS, Medicare, and other National and State standards of patient care.