Develops and manages the effective implementation of systems and process for risk management. Provides support and service to the hospital and its clinics by assisting in the prevention, reduction, and control of loss to its patients, visitors, volunteers, physicians, and employees. Lead patient safety efforts at the facility with support and connection to the market patient safety group. Provides analysis and evaluation of confidential data to identify clinical risk reduction opportunities. Works closely with the executive leadership team, site directors, managers and front line staff to assure patient safety is a top priority.
Develops and coordinates the processes for risk identification, risk investigation, and risk reduction; to include risk surveys, inspection of patient care areas, and chart auditing; assists in reviewing the facility to assess for loss potential. Facilitates root cause analysis investigations, FMEA methodologies, reporting of adverse events, and reporting of sentinel events to the appropriate parties. Standing member of all RCA's and Roundtable meetings.
Manages, collects, and evaluates data concerning patient incident reports, aggregates data summaries, and develops monthly and quarterly risk management reports that include trend analysis of incidents, claims, complaints and profiles. Maintains a hospital wide incident reporting system. Investigates and follows up potentially compensable events identified through the incident reporting process. Manages claims against the hospital interfacing with defense legal counsel, insurance adjustors, and corporate risk management. Investigates and analyzes actual and potential risks in the hospital; assess liability and probability of legal action for potential notification of insurance carriers.
Conducts surveys, studies, and special projects to assist in proactive risk activities. Conducts periodic assessments of hospital wide risk management activities to determine program effectiveness and assist in the development of corrective action plans. May assist in resolving treatment issues including patient refusal of treatment, consent issues, AMA's; may assist in issues surrounding end of life, advanced directives, and power of attorney. Acts as a resource for medical/legal inquiries of physicians, nurses, and administrators regarding emergent patient care issues and loss control.
May assist in resolving treatment issues including patient refusal of treatment, consent issues, AMA's; may assist in issues surrounding end of life, advanced directives, and power of attorney. Acts as a resource for medical/legal inquiries of physicians, nurses, and administrators regarding emergent patient care issues and loss control. Evaluates correspondence from attorneys, patients, and other outside sources and formulates responses as necessary. Records, collects, documents, maintains, and provides attorneys any requested information and documents necessary to prepare testimony in pending litigation.
Effectively facilitates implementation of site’s patient safety program including leadership and front line staff tools that promote reliability. This includes but is not limited to daily huddle, safety recognition, just culture, safety coach programs, physician champion programs. Leads the High Reliability Program at their home site, facilitating selection and training of safety coaches, leads coach training, ensuring training of all team members within the unit and assures a strong sustainment program is in place.
Ensures the timely investigation of all serious safety events by conducting a root cause analysis and use of other investigative tools. Identifies and oversees implementation of corrective actions to reduce risk in the organization, specifically identifying those that have system implications for risk reduction.
Communicates and presents regularly to site executive teams around the occurrence of serious safety events, and status of the site safety program. Provides regular education to team members and physicians at all levels of the organization regarding safety and reliability.
Reviews safety events reported daily. Analyzes patient safety data on a regular basis to identify strengths, opportunities for improvement, trends and actionable items to advance site culture.
Licensure, Registration and/or Certification Required:
Registered Nurse license issued by the state in which the team member practices.
Certified Professional in Patient Safety (CPPS) designation issued by the Certification Board for Professionals in Patient Safety (CBPPS) needs to be obtained within 1 year.
Bachelor's Degree (or equivalent knowledge) in Nursing.
Typically requires 7 years of experience in administrative work in a hospital setting in order to have knowledge of problems encountered in the delivery of healthcare, including experience in insurance/ loss control, risk management/ quality assurance issues and claims management/ insurance industry.
Knowledge, Skills & Abilities Required:
Must be proficient in Microsoft Office (Excel, Word, Power Point, and Access) or similar products.
Excellent communication skills (oral and written, group, and one-on-one).
Extensive knowledge of statistical methods, data analysis and presentation.
Awareness of key topics in the field of patient safety and reliability.
Demonstrated ability to analyze procedure and process changes.
Demonstrates the ability to lead others through influence.
Experienced in leading teams.
Training And Development