Assistant Director, Risk Management & Patient Safety

Assistant Director, Risk Management & Patient Safety

The University of Illinois Hospital & Clinics (UI Health) is seeking a full-time Assistant Director, Risk Management & Patient Safety. This position is responsible for the delivery of clinical risk management and patient safety services within assigned service lines throughout the state-wide University of Illinois clinical patient network and Mile Square Federally Qualified Healthcare Clinics. The University of Illinois clinical patient network includes the College of Medicine campuses at Rockford and Peoria, Department of Specialized Care for Children, and the University of Illinois College of Medicine clinics in the Chicago area. Risk management and patient safety services, as defined by the American Society for Health Care Risk Management, includes the domains of clinical patient safety, risk financing, legal and regulatory, health care operations, and claims and litigation. The Senior Risk Manager is responsible for overseeing the work of the Risk Manager within their service lines.

Duties & Responsibilities

Clinical Patient Safety

• Support the organization's Culture of Safety through leading Root Cause Analysis (RCA) of sentinel, serious harm and near miss events.
• Oversee timeline development by Risk Manager and conduct in person interviews with involved staff and subject matter experts.
• Utilize process mapping for RCA meeting presentations.
• Research evidence based best practices related to clinical processes.
• Recommend or develop related process improvement plans.
• Monitor process improvement plans through the organizational quality committee structure.
• Categorize events and contributing factors, oversee related data analysis by Clinical Data Practice Analyst and develop associated risk education for the organization and within assigned service lines.
• Lead the Critical Incident Debriefing (CID) process through identifying appropriate events for rapid review, overseeing initial fact gathering, timeline development and potential system improvements.
• In consultation with the Senior Director, determine appropriate events that require RCA or referral to the organizational quality committee structure.
• Oversee related data trending and analysis by Clinical Data Practice Analyst.
• Lead the investigation of events involving potential patient abuse by staff, including facilitating UIC police reporting, witness interviews, recommending administrative leave in consultation with Human Resources, securing video surveillance, ensure mandatory reporting obligations, communicate with patient on investigation progress and facilitate event through closure.
• Oversee the Risk Manager's review of patient safety events, including assignment of criteria-based harm and severity ratings.
• Review high harm events and oversee investigation of these including stabilization of the environment, witness interviews, record analysis, evidence retrieval, RCA or CID process and billing management.
• Serve as content expert for the medical error disclosure process.
• Provide contemporaneous and ongoing staff guidance on disclosure.
• Facilitate leadership consensus for disclosure of high harm events.
• Process may involve direct patient communication.
• Active leadership and participation in the Department's Care For the Caregiver program. Identify and refer staff for peer support. Participate in program training and periodic meetings.
• Lead or participate in National Patient Safety Goal Sub-committees, Failure Mode Effects Analysis (FMEAs) or other organizational patient safety committees or initiatives.
• Prepare or assist with reporting to the hospital wide Safety Committee.
• Maintain awareness of national patient safety initiatives and evaluate for inclusion to the organization's Safety program.
• Participate in 24/7 rotation providing University of Illinois and its affiliated Federally Qualified Healthcare Clinics system wide risk consultation.
• Maintain knowledge of healthcare operations provided state-wide within assigned service lines.
• Provide Consultation within service lines of potential workplace violence issues.
• Oversee the risk Manager's development of behavioral contracts, notification of University of Illinois police, and warning and termination letters. Engage with University of Illinois police and internal and external legal counsel as necessary.

Risk Financing

• Refer events to the appropriate University insurance programs that include potential medical malpractice, general liability, workers compensation and property claims.
• Support the preparation of the Senior Director's annual medical malpractice reinsurance renewal with data related to service line events and risk and patient safety initiatives.

Legal and Regulatory

• Liaison with Accreditation and Clinical Compliance on regulatory event investigations and periodic accreditation surveys within assigned service lines.
• Participate or lead fact-finding in regulatory investigations, associated system improvements and external reporting. Investigate and prepare responsive documents for healthcare plan quality of care inquiries.
• Advise on legal and regulatory issues including those related to informed consent for patient care, patient abuse and neglect, Illinois Healthcare Surrogate Act, Safe medical Devices Act (SMDA), medical record documentation, patient termination, withdrawal of care and patient privacy outlined in the Healthcare Insurance Portability and Accountability Act (HIPAA).
• Investigate or oversee referred healthcare compliance investigations and partner in resolution with Hospital Compliance.

Health Care Operations

• Proactively identify risk assessment opportunities within assigned service lines.
• Perform or supervise outside risk consultant risk assessments.
• Engage service line stakeholders in the risk assessment process.
• Lead or facilitate resulting recommendations in collaboration with service line and hospital leadership. Evaluate ongoing effectiveness of implemented strategies.
• Develop and present risk and patient safety education within assigned service lines. Develop patient safety stories resulting from RCAs and CIDs for organizational learning.
• Develop or review hospital and departmental policies, guidelines and protocols in consultation with the Senior Director for assigned service lines.
• Participate in Safety Leader Walkrounds. Assist Senior Director with resolution of assigned related follow-up.
• Oversee Risk Manager evaluation of referred patient complaints from Patient and Guest Experience.
• Oversee Risk Management and Patient Safety reports prepared by Clinical Practice Data Analyst regarding targeted and ongoing issues.
• Assist Senior Director with content and presentation for Resident bi-monthly Risk and Patient Safety meetings.
• Prepare relevant risk and safety information for medical staff quality meetings within assigned service lines.
• Attend departmental peer review committees and advise on peer review issues within assigned service lines.
• Identify appropriate cases for referral to multidisciplinary physician peer review and nursing peer review committees.
• Identify and document referral issues in the patient safety event report.

Claims and Litigation

• Identify and refer appropriate claims or potential medical malpractice or general liability litigation matters to University Claims.
• Advise physicians and staff regarding next steps with summons and complaints and related legal documents.
• Actively participate in quarterly medical malpractice case reviews by proactively identifying practitioner issues and associated system process improvements.
• Assist Senior Director with database collection and categorization of filed lawsuits and complaints.
• Utilize closed case summaries to develop targeted risk education.
• Assist University Claims staff with discovery production within assigned service lines.
• Delegate select claims requests to Risk Manager and review prior to production.
• Perform other related duties and participate in special projects as assigned.

Minimum Qualifications

• Bachelor's degree in healthcare or related field required.
• Minimum of seven years clinical hospital or clinical risk management experience required.
• CPHRM designation preferred or must obtain within one year of hire.

Preferred Qualifications

• RN licensure in the state of Illinois preferred.
• Master's degree in healthcare related field, MBA/MHA or JD degree preferred.
• Five years of clinical risk management experience preferred.

ICARE: Patient & Employee Values Our Values & I CARE (Inclusion, Compassion, Accountability, Respect, Excellence) Standards

I nclusion: We believe diversity is our strength and do not tolerate discrimination in any form. We recognize and celebrate differences and uniqueness amongst our patients, staff, and faculty to ensure that everyone feels valued and respected.

C ompassion: We will treat our patients and their families with kindness and compassion and strive to better understand and respond to their needs.

A ccountability: We will hold ourselves accountable as an organization and as individuals to act ethically and with integrity in everything we do, to be excellent stewards of our natural and financial resources, and to be transparent in our actions.

R espect: We will act with respect, openness, and honesty in our relationships with patients, families, and coworkers