CS-214 Position Description Form



+CS-214Rev 11/2013Position CodeState of MichiganCivil Service CommissionCapitol Commons Center, P.O. Box 30002Lansing, MI 48909POSITION DESCRIPTIONThis position description serves as the official classification document of record for this position. Please complete this form as accurately as you can as the position description is used to determine the proper classification of the position. 2.Employee’s Name (Last, First, M.I.)8.Department/AgencyVACANTDEPARTMENT OF HEALTH AND HUMAN SERVICES/ KALAMAZOO PSYCHIATRIC HOSPITAL3.Employee Identification Number9.Bureau (Institution, Board, or Commission)VACANTBUREAU OF STATE HOSPITALS AND BEHAVIORAL HEALTH ADMINISTRATIVE OPERATIONS4.Civil Service Position Code Description10.DivisionDEPARTMENTAL ANALYST-A 12KALAMAZOO PSYCHIATRIC HOSPITAL5.Working Title (What the agency calls the position)11.SectionQUALITY AND COMPLIANCE ASSISTANT DIRECTORADMINISTRATION6.Name and Position Code Description of Direct Supervisor12.UnitCONOR MOORE, STATE ADMINISTRATIVE MANAGER-17.Name and Position Code Description of Second Level Supervisor13.Work Location (City and Address)/Hours of WorkJILL KRAUSE, SENIOR EXECUTIVE HOSPITAL DIRECTOR1312 OAKLAND DRIVE, KALAMAZOO, MI 49008MONDAY THROUGH FRIDAY 8AM TO 4:30PM14.General Summary of Function/Purpose of PositionThis position serves as a key member of the Quality and Compliance Department, with primary duties including: data collection and analysis pertaining to risk management; identification and reporting of liability and vulnerability factors; assist in providing oversight of the environment of care and emergency management programs; and assistance with the implementation and monitoring of quality improvement activities. The incumbent of this position will also assist with activities to assure compliance with Joint Commission and other regulatory standards, and be assigned special projects by the Quality and Compliance Director that are in line with the responsibilities of the department. 15.Please describe the assigned duties, percent of time spent performing each duty, and what is done to complete each duty.List the duties from most important to least important. The total percentage of all duties performed must equal 100 percent.Duty 1General Summary of Duty 1% of Time 20Assist to assure compliance with Joint Commission Standards, CMS Regulations, DHHS policies and State of Michigan Rules and Laws that apply to the hospital.Individual tasks related to the duty.Assist with the completion of The Joint Commission Intra-cycle monitoring process.Help coordinate and participate in audit and survey preparation activities such as show proof preparation, mock surveys, etc.; as well as corrective action activities.Work with departments to assist with on-going compliance to policies, regulatory standards, and applicable State of Michigan Rules and Laws. Duty 2General Summary of Duty 2% of Time20Review and report hospital activities for areas of risk to patient, staff, liabilities, fraud, pro-active risk management, etc. Individual tasks related to the duty.Assist with the implementation, revision, and monitoring of the hospital’s Risk Management Plan.Assist in providing incident data reports in regard to the hospital’s safety related activities to Joint Commission/ORYX/NRI data submission, Environment of Care, Medication Error Reporting, etc.Assist in the review of medical records, incident reports, and summaries of monthly injury reports to assess for quality of care issues.Review/monitor daily 24-hour reports, reporting risk-related concerns.Monitor emergency room usage, trends, and appropriateness of care. Analyze data and submit reports to the Quality and Compliance Director. Work collaboratively with all departments and Office of Recipient Rights (ORR) to identify and resolve risk issues. Participate in root cause analysis of sentinel events as assigned.Duty 3General Summary of Duty 3% of Time 20Outcomes data collection, reporting, and analysis to promote hospital performance improvement activities. Individual tasks related to the duty.Verify data validity and integrity, collaborating with other departments as needed.Assist the department with the implementation, maintenance, and monitoring of performance improvement measures to improve data validity and integrity.Participate in the Performance Improvement Committee.Assist the department secretary to complete NRI reporting.Work with Quality and Compliance Director to create and maintain an outcomes collection and reporting schedule.Prepare outcomes reports as assigned which include data analysis and performance improvement measures as appropriate. Oversee data collection and participation in the National Incident Management System (NIMS).Duty 4General Summary of Duty 4% of Time 20Help facilitate the KPH Emergency Management Program.Individual tasks related to the duty.Assist with drills and tabletop exercises.Participate in the Region 5 Emergency Management meetings as required.Maintain the Disaster Response Manual and participate in the development and implementation of disaster and emergency plans to ensure the safety of patients, employees, and visitors.Ensure compliance to Joint Commission standards in regard to emergency management.Assist in identifying emergency management best practices and training materials.Assist in chairing the Emergency Management Committee meetings.Duty 5General Summary of Duty 5% of Time 10Participate in special projects as assigned by the Quality and Compliance Director.Individual tasks related to the duty.Collaborate with other KPH staff and departments as needed.Provide Quality and Compliance Director with regular project updates.Follow through with projects in the allotted timeframe.Act as the back-up designee for Freedom of Information Act inquiries.Duty 6General Summary of Duty 6% of Time 10Other duties as assigned.Individual tasks related to the duty.Attend committee meetings when the Quality and Compliance Director is unavailable.Assist with the Medical Records Department as needed.16.Describe the types of decisions made independently in this position and tell who or what is affected by those decisions.Independent decisions made in collecting and reviewing data pertaining to risk management and compliance related activities. When functioning in emergency management situations, must be able to function independently, using sound judgement to make decisions. 17.Describe the types of decisions that require the supervisor’s review.Supervisor review of data analysis and recommendations for risk management and compliance-related activities. 18.What kind of physical effort is used to perform this job? What environmental conditions is this position physically exposed to on the job? Indicate the amount of time and intensity of each activity and condition. Refer to instructions.Sitting, standing, walking, writing, computer use and telephone use occur frequently.Stooping, bending, kneeling, reaching, lifting and carrying occur occasionally.19.List the names and position code descriptions of each classified employee whom this position immediately supervises or oversees on a full-time, on-going basis. (If more than 10, list only classification titles and the number of employees in each classification.)NAMECLASS TITLENAMECLASS TITLENone.20.This position’s responsibilities for the above-listed employees includes the following (check as many as apply):Complete and sign service ratings.Assign work.Provide formal written counseling.Approve work.Approve leave requests.Review work.Approve time and attendance.Provide guidance on work methods.Orally reprimand.Train employees in the work.22. Do you agree with the responses for Items 1 through 20? If not, which items do you disagree with and why?Yes.23.What are the essential functions of this position?The essential functions of this position include: assisting with activities to assure compliance with Joint Commission and other regulatory standards; completion of data collection and analysis pertaining to risk management; identifying and reporting liability and vulnerability factors; assisting with the oversight of the emergency management program; and assisting with the implementation and monitoring of quality improvement activities. 24.Indicate specifically how the position’s duties and responsibilities have changed since the position was last reviewed.New position.25.What is the function of the work area and how does this position fit into that function?This position is assigned to the Quality and Compliance department which is responsible for managing the KPH Risk Management program, quality improvement activities, and the emergency management program. The department is also responsible to ensure compliance with Joint Commission Standards, Center for Medicare/Medicaid Services (CMMS) Regulations, DHHS policies and procedures, State of Michigan Administrative Rules and Laws that apply to the hospital.26.What are the minimum education and experience qualifications needed to perform the essential functions of this position?EDUCATION:Possession of a bachelor’s degree in any major.EXPERIENCE:Three years of professional experience, including one year of experience equivalent to the experienced (P11) level in state service.KNOWLEDGE, SKILLS, AND ABILITIES:Ability to collect, analyze, and evaluate data for the purposes of risk management and quality improvement.Ability to interpret laws, rules, and regulations relative to KPH.Fluent in Microsoft Word and Excel required, experience in Microsoft Visio and Access preferred. Flexibility and capability to handle multiple tasks timely and efficiently.Effective communication skills, both written and verbal.CERTIFICATES, LICENSES, REGISTRATIONS:None NOTE: Civil Service approval of this position does not constitute agreement with or acceptance of the desirable qualifications for this position.I certify that the information presented in this position description provides a complete and accurate depiction of the duties and responsibilities assigned to this position. Supervisor’s SignatureDateTO BE FILLED OUT BY APPOINTING AUTHORITYIndicate any exceptions or additions to statements of the employee(s) or supervisors.I certify that the entries on these pages are accurate and complete. Appointing Authority SignatureDateTO BE FILLED OUT BY EMPLOYEEI certify that the information presented in this position description provides a complete and accurate depiction of the duties and responsibilities assigned to this position. Employee’s SignatureDateNOTE: Make a copy of this form for your records. ................
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