Irena Kay Hoffmann Email & Phone Number

Denham Springs, La, Us

Baton Rouge, La

➤ Orchestrating and managing data collection, report generation, and review of identified issues related to infection control➤ Reporting program updates and metrics to the Administrator and department managers as well as any escalations➤ Maintaining communication with the leadership team to obtain feedback on initiatives and address compliance issues➤ Remaining current on the latest state, federal, CMS, and TJC regulations to serve as the internal regulatory resource➤ Serving as a consultant on patient/member safety based on analysis of complaints, grievances, and unusual occurrences➤ Reviewing customer feedback to address quality issues such as patient satisfaction surveys and complaints or grievances➤ Recommending revisions to policies and procedures to eliminate/reduce risk and to prevent future occurrences➤ Investigating any documented complaints from patients and providing data analysis to senior leadership for the results➤ Directing quality assurance, process improvement, and infection control while serving as a patient advocate➤ Managing risk for a 53-bed facility and serving as contributor to the leadership team while providing customer service➤ Serving as a resource to Health Care System subsidiaries regarding compliance with laws, standards, and requirements➤ Reporting serious incidents/sentinel events to government bodies in accordance with contracts, policies, and procedures.

Baton Rouge, La

➤ Performed statistical analyses to identify trends, variations, patterns, and insights to manage and mitigate operational risk➤ Conducted investigations and audits and took appropriate actions to resolve any concerns, complaints, or grievances➤ Used Microsoft Excel functions such as pivot tables, charts, and reports to break down and analyze information➤ Analyzed data and compiled and submitted regular reports to update senior management on operations and progress➤ Maintained updated knowledge regarding compliance and revised standards through monthly and quarterly reports➤ Led regular meetings with department managers to improve service and reported findings to Committee of the Whole➤ Ensured compliance with contractual arrangements such as grants including those governing professional practice➤ Provided risk reviews of legal contracts impacting operations in conjunction with the VP of Risk and Accreditation➤ Prepared and delivered regular reports including findings from analysis, response actions, and trend analysis➤ Designed standardized data gathering, tracking, display, and storage system for the Risk Management Program➤ Maintained complete documentation to meet regulatory reviews and ensured adherence to standards and requirements➤ Built relationships with departments and internal/external customers to enhance communication on risk and safety➤ Investigated and analyzed actual or potential risks in the institution and assessing liability or probability of legal action➤ Coordinated and facilitated performance of root cause analyses and providing recommendations for improvement.