Didra Cantu

The Senior Quality/Risk Director is responsible for a culture that enables the hospital to fulfill its mission by meeting or exceeding goals, facilitating staff accountability for performance, and motivating staff to improve performance. This role manages, directs, and plans all aspects of Quality and Risk Management. This role oversees the hospital-wide quality management program and works with hospital administration, departments, and the medical staff to monitor and evaluate the quality of delivery of patient care services. This role has access to all medical records for the hospital; ensures proper compliance with regulatory agencies, accrediting bodies, and Home Office and hospital policies and procedures; and develops, implements, and maintains quality assessment and improvement programs within the hospital.

- In addition their hospital-based responsibilities, the Senior DQR assists the RDQR with the following at other hospitals in the region:
- Joint Commission preparedness and response (including mock surveys)
- MRCA and ADR reviews/submission
- Serving as formal back-up for RDQR and hospitals with DQR vacancies
- Preparing new hospitals, conducting training initiatives, precepting, recruiting, etc.
- Assesses compliance with federal, state, and industry regulatory and accreditation standards.
- Facilitates processes to remediate and/or maintain compliance.
- Provides organizational education related to the regulations and standards.
- Compiles data in usable formats for analysis against appropriate benchmarks, using current statistical tools and techniques in an effort to identify improvement opportunities.
- Successfully completes annual skills competency required.
- Coordinates local/state/federal/accreditation surveys and associated action plans and assessments.
- Submits corrective action plans and assessments (i.e. TJC PPR) to regulatory and accrediting bodies within required timeframe.
- Oversees oversight of corrective action plan through ongoing monitoring.
- Maintains appropriate records and documentation of Quality Council, MEC, and Governing Body activities including minutes, supporting data, logs, and all related documents in accordance with state and federal law.
- Facilitates committees, teams, and plan documentation for performance improvement.
- Ensures that the following PI teams are in place: falls PI committee, FMEA, and others per hospital priorities.
- Ensures updates and maintenance of hospital plans is completed.
- Manages implementation of hospital policies and applicable company policies.
- Coordinates the review, revision, development, approval and implementation of hospital specific policies.
- Coordinates the implementation of corporate policies applicable to the hospital.
- Collaborates with other departments to coordinate care and resolve customer concerns or complaints.
- Oversees complaint process including complaint investigation; verbal and written complaint follow-up; corrective action planning; and maintenance of complaint log.
- Resolves issues promptly as outlined in the Corporate Patient Complaint/Grievance Policy.
- Coordinates all RCA (root cause analysis) and sentinel event report development and submission.
- Submits reports to required local, state, federal and accreditation agencies related to sentinel events and mortality as required by local/state/federal jurisdiction and/or accreditation agencies.
- Shares Patient Satisfaction data with leadership/staff monthly (min.) and coordinates improvement. Identifies opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction.
- Oversees risk management activities including completion of reports/claims/plans.
- Completes incident reports, notice of potential claims, corrective action planning and incident reporting to Corporate Risk Manager.

The Quality/Risk Director is responsible for an environment and culture that enables the hospital to fulfill its mission by meeting or exceeding goals, conveying the mission to all staff, facilitating staff accountability for performance, and motivating staff to improve performance. Assesses compliance with federal, state, and industry regulatory and accreditation standards.

― Facilitates processes to remediate and/or maintain compliance, including monthly and/or ongoing reviews, and compliance with the CMS IRF Quality Reporting Program (QRP).

― Provides organizational education related to the regulations and standards.

― Manages the monthly Quality Dashboard process to aggregate and assess the hospitals quality and operational programs.

― Compiles data in usable formats for analysis against appropriate benchmarks, using current statistical tools and techniques in an effort to identify improvement opportunities.

― Manages the credentialing process for providers in coordination with the Encompass Health Credentialing Office (EHCO).

― Prepares and submits timely, statistically correct, complete reports of risk management and quality information to the appropriate hospital, regional, corporate, or external agency.

-Supports the PASC position(s) in the completion of their roles and responsibilities, including timely completion of IRF-PAIs, Quality

Indicator (QI) training and credentialing.

- Coordinates local/state/federal/accreditation surveys and associated action plans and assessments.

― Submits corrective action plans (i.e. TJC Evidence of Standards Compliance) to regulatory and accrediting bodies within required timeframe.

― Oversees corrective action plans with responsible parties through ongoing measurement and monitoring.

― of Quality Council, MEC, and Governing Body activities including minutes, supporting data, logs, and all related documents in accordance with state and federal law.

- Facilitates committees, teams, and plan documentation for performance improvement activities per the Performance

Improvement & Safety Plan.

― Ensures that the following PI teams are in place: falls committee, Proactive Risk Assessment, and others per hospital priorities.

― Encourages others to serve as PI team leaders and facilitators.

― Maintains current hospital plans in Hospital Policy on Demand (HPOD) (for example Plan for the Provision of Care/Scope of

Services, Leadership, Information Management, Utilization Review, Infection Control, Performance Improvement and Patient Safety).

― Ensures the implementation of hospital policies and protocols in HPOD at each quarterly cycle, or as needed.

― Coordinates the review, revision, development, approval and implementation of hospital policies.

― Acts as an organizational liaison with the CEO and Corporate Compliance to ensure implementation of the Standards of

Business Conduct and all applicable compliance policies.

• Collaborates with other departments to coordinate care and resolve patient and caregiver concerns or complaints.

― Encourages reporting of complaints and grievances and their prompt resolution in complaint database.

― Oversees complaint process including complaint investigation; verbal and written complaint follow-up; corrective action planning; and maintenance of eCALM.

― Resolves issues promptly and ensures verbal/written follow-up occurs within required timeframes as outlined in the

Patient and Customer Complaint or Grievance Policy (INT 008).

― Coordinates all RCA (root cause analysis) and sentinel event report development and submission.

― Submits required reports to local, state, federal and accreditation agencies.

― The first draft of the RCA is due to the Regional Director of Quality within 30 days from the event of or notice of the event.

• Involved in the denial management process involving Medicare, Medicare contractors, and other payors.

• Shares Patient Satisfaction data with leadership/staff monthly (min.) and coordinates improvement.

― Identifies opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction per the

Patient Experience CPR TeamWorks program.

• Oversees risk management activities to include, but not limited to:including completion of reports/claims/plans. ― Review and follow-up as needed on RLDatix reports.

― Assist defense counsel and Third Party Administrator with investigating and responding to litigation.

― Serves as local contact with Home Office Risk Staff.

― Acts as Patient Safety Organization (PSO) hospital-based contact:

▪ Designates whether a report is “sent” or “copied” to the PSO.

▪ Consult with Home Office PSO/Risk staff before providing information sent to PSO.

• Uses a variety of applications to perform technical analyses and planning.

― Identifies improvement opportunities, generates reports, researches issues, identifies resources, and accesses external databases.

― Maintains familiarity with company applications including but not limited to Beacon, Patient Registration, UDS, and NRC Health.

• Organizes, plans, and manages time effectively to complete assignments.

• Meets position requirements and performs essential functions.

• Reports questionable situations, concerns, complaints or harassment immediately.

• Patient Safety Officer and oversight of Patient Safety Program
• Management of Hospital Occurrence Reporting System
• Oversight of State and Federal Regulatory Reporting
• Stroke Coordinator and Stroke Program Management
• Responsibility of House Supervisors and Hospital throughput coordination of patients, and Dialysis Contracts, Physical Therapy, Occupational Therapy, and Speech Therapy
• Management of Hospital Patient Complaint Program
• Oversight of Regulatory reviews for State and Federal investigations
• Hospital Resource for The Joint Commission, Centers for Medicare and Medicaid Services (CMS), Title 22, EMTALA, Consent Law
• Oversight of Hospital Policies
• Management of The Camden Group’s “Throughput Evaluation”
• Oversight of Hospital Litigation, Discover, Potentially Compensable Events and Claims Management
• Accountability for managing and implementing plans of corrections for regulatory compliance
• Committee Member of Medical Executive Board, Medical Quality and Peer Review Compliance, Pharmaceutical and Therapeutic, Performance Improvement, Patient Safety, Radiation Safety, Patient and Employee Satisfaction.
• Received successful survey results for hospital, lab, radiology, medication error reduction plan, patient safety and dietary, by state, federal and joint commission.
• Risk Management / Patient Safety
• Cleared Centers for Medicare and Medicaid Services Validation Survey during initial survey (2012)
• During tenure, no Adverse Event-California Department of Public Health/ CMS 2567 Plans of Corrections citings
• During tenure, no Hospital litigation filings of Summons or Complaints
• Noted as implementing “Best Practice” during The Joint Commission’s Primary Stroke Center Survey: Achieved Primary Stroke Certification (2012).
• Led Hospital to being recognized as top ranked hospital in California for patient safety according to Consumer Reports Magazine (July 2012).
• Coordinated to implement strategies to address patient concerns and customer service, resulting in improved patient satisfaction scores from 60% to high 80%.
• Developed plan and worked closely with Nursing Leadership, Infection Control Coordinator, VP Clinical and physicians to improve wound care to have no Hospital Acquired Pressure Ulcer, Stage III -IV
• Designed and implemented Patient Safety Program to include best practices and The Joint Commission
• Designed and implemented Event Reporting Structure to include severity of impact to hospital; reduced Departures from Against Medical Advice and Emergency Department Left Without Being Seen
• Designed and implemented Risk Management Best Practice “ No Harm” Scorecard
• Coordinate and deliver Risk Management and Loss Prevention reduction practices
• Oversight of The Camden Group’s “Throughput Evaluation”

· Implementation of Stroke Program and Brain + Spine Clinic

· Physician strategy negotiation for contract managing and program development

· Facilitate, monitor and communicate organizational survey readiness programs for federal, state and local survey including facilitating and coordinating California Department of Public Health, Centers for Medicare and Medicaid Services, The Joint Commission, and other Regulatory agency visits.

· Participates in the review of policies and procedures to support compliance to regulatory requirements.

· Ensures that ongoing monitoring and action plans are communicated to appropriate hospital departments, executive leadership, Medical Staff and the Board of Directors.

· Facilitate education in risk and quality activities relating organizational integrity practices, corporate compliance, false claims, Stark, Anti-kickback, HIPAA, NPSG, EMTALA, Centers for Medicare and Medicaid Services Tags and the Joint Commission Elements of Performance in New Hire Orientation Program, leadership orientation and annual competencies. Successfully provided 2567 Statement of Deficiencies responses accepted by California Department of Public Health and Centers for Medicare and Medicaid Services

· Successfully implemented an Organizational Contract Management process for Supply Management

· Successfully collaborated to close investigations with the OIG for civil monetary penalties relating to EMTALA eliminating a potential fine of up to $50,000

· Successfully educated 1400 employees and implemented a strategic plan to provide Corporate Compliance to NPSG achieving 100 percent compliance during Corporate Validation Audit.

• Supervision of Risk and Compliance activities for Mercy Hospitals including corporate compliance, claims management, litigation, consent law, data collection, analysis, education, standards and other areas of loss prevention and regulatory oversight;
• Coordinate and maintain Compliance Program in conjunction with the Director of Risk and Compliance;
• Coordinate and participate in multi-faceted education and training programs that focus on the elements of the Compliance Program for pertinent Federal, State, and Compliance Program standards;
• Supervise Contract Management process for contract initiation, amendments, monitoring, tracking, executing and reporting status of contract changes, clarifying and tracking contract change agreements, and monitoring any unauthorized contract changes;
• Coordinate and maintain Certificates of Insurance, Liability, and Vehicle Insurance
• Coordinate with Executive Leadership a Patient Safety framework and assist in the implementation and evaluation of patient safety related policy and procedures;
• Participates in and provides recommendations for patient safety curriculum for the organization that supports evidenced based practices including Tracer Methodology as utilized by Regulatory Agencies;
• Assess the culture and practice of patient safety through established tools, annual surveys, listening and learning methods;
• Provides education and feedback to all executive leadership and facility team members relating to patient safety and facility compliance to Regulator Agencies;
• Serves as a resource within the organization for Consent
• Coordinates Risk Management Root Cause Analysis (RCA) to complete investigations within specified time frames and provide information to leadership to monitor implementation of recommendations;
• Recommends and participates in the management and resolution of risk-related claims and litigation;
• Coordinates with the Director of Risk and Compliance proper reporting of violations or potential violations to Regulatory Agencies as appropriate and/or required;
• Participates in Compliance Program through assurance of an employee code of conduct, establishing written standards, including policies and procedures, in order to assure legal and ethical compliance;