Position Description: System Director, Loss Prevention & Compliance Services
Daughters of Charity Health System

Our Client

The Daughters of Charity Health System (DCHS) is a prestigious regional healthcare system of five hospitals spanning the California coast from the Bay Area to Los Angeles. It is regarded as one of the best Systems in California.  Its sponsors are the Daughters of Charity of St Vincent de Paul.  The core value of the organization is “providing quality, compassionate, holistic care to all who come to us, helping to heal them in body, mind and spirit.”

Until 1995, the Daughters of Charity hospitals were part of the Daughters of Charity National Health System.  In the 1995, the Daughters of Charity hospitals of the West merged their hospitals with Catholic Healthcare West (CHW), responding to market pressures and perceived opportunities to strengthen the wider Catholic healthcare system in California.

In 2001, after careful reflection, the Daughters of Charity began a process to withdraw from CHW and, once again, directly sponsor their six hospitals as the newly created Daughters of Charity Health System.

DCHS encompass some of the finest physicians, nurses, staff and facilities in the state. The facilities include O'Connor Hospital, San Jose; Seton Medical Center, Daly City; Seton Coastside, Moss Beach; St. Francis Medical Center, Lynwood; St. Louise Regional Hospital, Gilroy; St. Vincent Medical Center, Los Angeles; and Central Business Services, Redwood Shores, which provides support services to the Northern California hospitals.

Management

An overview of top management of the hospital system shows an exceptional blend of clinical, operational and business expertise in the field of acute and specialty care and services.  Underlying the management team's skill-set is a passionate, deep-seeded and visionary commitment to excellence, innovation and growth.  The style of management and the organizational culture of excellence are deeply rooted in teamwork and mutual support. 

The level of teamwork and support among the management staff is extraordinarily high and remarkably effective.  This group of Managers, Directors and Senior Executives, with their collaborative style and complete commitment to the mission, is the heart of the department’s success.  It is readily apparent that the management team consistently emphasizes teamwork, individual achievement and making the job fun.

To complement the management team, an individual must be able to blend their individual success into that of the entire team and share in the commitment and the satisfaction of taking care of the healthcare needs of the community.

Reporting Relationship

The Director, Loss Prevention & Compliance Services reports to the Vice President, Risk Management & Corporate Responsibility Officer.

Position Description

The Director, Loss Prevention & Compliance Services of the Daughters of Charity Health System is responsible for managing the DCHS system-wide corporate responsibility program and for providing risk management loss prevention services its hospitals.

Responsibilities and Proficiencies

• Plans, directs, and develops educational materials and programs to address training needs identified throughout DCHS or by an individual hospital to address risk management, loss prevention/control, regulatory requirements and standards, etc.
• Designs and implements risk assessments to identify areas of exposure and opportunities for improvement. Analyzes findings from assessments to identify patterns and trends that could result in compensable events. Findings of surveys, studies and special projects are used to assist in long term planning and to identify changes needed to policies and systems to facilitate reductions in risk and losses.
• Collaborates with senior administrative and clinical leaders and the hospital’s risk managers to develop action plans that address opportunities for improvement identified in the risk assessment and facilitate implementation of the plan through education, consultation and on-site assistance.
• Evaluates loss prevention and education practices and programs at the hospitals and assists in the development of programs and tools to reduce the frequency/severity
• Operate and maintain the DCHS Global Compliance Services "hotline" that allows compliance, privacy and security issues to be reported by associates anonymously.
• Coordinate follow-up with LEM Corporate Responsibility Officers (CRO) to ensure calls are investigated thoroughly and responded to promptly.
• As necessary, update the DCHS Corporate Responsibility Program and related supplementary policies and procedures.
• Research and keep abreast of existing and new federal and state regulations regarding compliance issues as well as current interpretations of those statutes, rules, and regulations.
• Develop and coordinate appropriate annual compliance education programs for the hospital’s CROs. Assess the need for additional training and education and develop appropriate compliance and educational materials.
• Participate in the design and implementation of effective monitoring and auditing of compliance processes throughout DCHS.
• Work closely with the hospital’s CROs in evaluating corrective action plans.
• Conduct and participate in audits when necessary.
• Assist in the development of risk analysis tools, conduct risk analyses and develop monitoring tools for key areas.
• Continually improve the compliance audit program and implement any necessary changes on an ongoing basis to improve the prevention and detection of noncompliance.
• Serve as a resource to leadership in regards to compliance issues.
• Serves as the HIPPA Privacy Officer for DCHS. Works closely with the Privacy Officers at the hospitals and assists with their compliance activities.
• Knowledge of insurance, risk management, corporate compliance and the law as acquired through an advanced degree or special certification such as MHA/MBA, LLB/JD, ARM, ERM or equivalent degree or studies.
• Familiarity with California, federal, and other regulatory requirements and resources for monitoring health care compliance issues.
• Knowledge of insurance, risk management, corporate compliance and the law as acquired through an advanced degree or special certification such as MHA/MBA, LLB/JD, ARM, ERM or equivalent degree or studies.
• Familiarity with California, federal, and other regulatory requirements and resources for monitoring health care compliance issues.

Credentials and Qualifications

Education: B.A. or B.S. degree from an accredited university with emphasis on health care management. Masters' degree preferred.

Experience: Minimum five (5) years of progressively more responsible experience in health care risk management and corporate compliance.  Three (3) years of experience must be in a multi‑location healthcare system is highly preferred.

Personal Characteristics

The Director, Loss Prevention & Compliance Services needs to possess the patience, self-confidence and communication skills necessary to work with the clinical and administrative staff and the Physicians.

First and foremost, this individual needs to be a team player, be a superb communicator and have the style of a diplomat, i.e., be able to work in harmony with other operational entities and to negotiate agreements so each party benefits. It is imperative that he/she be skilled in bringing together the staff functions in a spirit of harmony and with a single-minded purpose.

A hands-on leader who can develop a strategic vision of the department and has the expertise to develop values and goals for a diverse group of constituents will be successful.  The successful candidate will have a proven record of accomplishment of strong leadership skills to ensure that the improvement process within the department continues, that priorities are established and the goals are met.

The successful candidate will be a person who possesses a strong work ethic, rejects setbacks and values accomplishments highly.  An action-oriented personality that deals with specifics within a broad conceptual framework will be most effective in this position.  This individual will have an appropriate sense of urgency to react to situations quickly and decisively.

Compensation

The compensation plan is based on a competitive base salary.  The hospital has an excellent employee benefits package, consisting of medical coverage, a dental plan, life insurance, Defined Benefit Retirement Plan and a matching 403 B program.

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