• Directs the initial intake processes of adverse hospital and patient events and event reporting, ensuring timely analysis and follow-up.
• Provides advice, consultation, and support to hospital and professional staff on clinical, risk, and ethical issues.
• Responds to sentinel events and other serious occurrences and provide expert advice in the management and reporting of such events to administrative and clinical leadership and staff.
• Oversees the investigation of patient/visitor incidents that have the potential for litigation and financial loss. Ensures that all information necessary to prepare for the analysis and defense of claims is collected and provided to the Director of Claims.
• Oversees and participates in the 24/7 on-call system of accessibility by staff to provide immediate consultation, mitigation, and recommendations in responding to adverse events.
• Actively participates in the Daily Safety Huddle and ensures there is daily risk management presence
• Directs investigations related to targeted incidents and adverse events, including interviewing staff and reviewing medical records for evaluation of clinical data, measurement of improvement, and/or regulatory liability reporting.
• Proactively evaluates areas of organizational risk based on internal assessment and external benchmarking; and, implements strategies and policies, which promote patient and staff safety.
• Promotes the organization-wide online incident reporting process including, trending and reporting results, identification of problem-prone areas, and the facilitation of prevention initiatives.
• Actively engages with key stakeholders to resolve safety issues and trends that are identified at the Daily Safety Huddle and safety reports
• Collaborates with physician leadership on case reviews and the formal professional practice evaluation process
• In collaboration with our Captive leadership, reviews cases and determines events that are appropriate for our CANDOR process
• Designs and presents educational programs on patient safety and risk management for all leaders, employees, and physicians. Assists clinical chairs and department chiefs to design risk management programs specific to their areas.
• Manages an electronic database for tracking patient safety events. Analyzes data to identify trends and opportunities to improve patient safety and report findings.
• Consistently exemplifies behaviors that support a strong culture of safety.
• Actively participates in the development, revision, and maintenance of policies needed to prevent or reduce loss exposure. Ensures policies and procedures meet all regulatory and accreditation requirements.
• Leads the review of serious occurrences requiring Collaborative Case Reviews or Failure Mode & Effects Analysis.
• Meets regularly with Executive and Medical Staff Leadership to provide detailed reports on all serious incidents, claims, and risk-related issues.
• Develops risk management reports for the Boards, senior management, clinical leadership, and external boards and agencies as appropriate. Prepares and presents reports, cases, bench marking data, and other educational information to the Claims Committee.
• Coordinates claims investigation, medical record requests, and legal defense processes.
• Serves as a liaison to external regulatory agencies for purposes of appropriate adverse event reporting to the Department of Public Health, Board of Registration in Medicine, FDA, etc., and coordinates surveys by the Department of Public Health.
• Assists in the identification and development of information related to equipment failures to ensure compliance with the reporting requirements of the Safe Medical Devices Act. Submits related reports via MedSun.
• Keeps up to date with new and revised state and federal regulations and statutes, Bylaws and regulations, and Safety Alerts related to hospital and patient care.
• Maintains ongoing awareness of rapidly evolving rules, regulations, and laws needed to keep in compliance with all external stakeholder requirements.
• Tracks and trends Serious Reportable Events (SRE) and Adverse Events.
• Assists with the completion of BORM reporting requirements including but not limited to: Annual reports, Semi-annual reports, Annual Disciplinary Reports, and Safety and Quality Reports (SQRs).
• Updates the Patient Care Assessment Committee Plan annually.
• Respond to agency requests and create corrective action plans if needed.
• Oversight of onsite regulatory reviews including notification to leadership and providing written summary of events.

Requirements

• Thorough understanding of QI processes, tools and techniques, quality measurement and reporting, TJC standards, Board of Registration in Medicine and Department of Public Health regulations, Collaborative Case Reviews, and preventive risk management strategies
• Requires strong organizational skills, persistence, creativity, and strong communication, interpersonal, and systems thinking skills
• Confidentiality is imperative to the success of this role
• Must have interpersonal skills necessary to deal effectively with administrative and clinical leadership, staff, Clinical Chairpersons, and other healthcare professionals
• Ability to effectively interview individuals and groups from diverse professional backgrounds
• Ability to collect event information and organize into a coherent narrative
• Highly self-motivated. Ability to manage multiple projects simultaneously and adhere to work deadlines.
• Ability to inspire trust and be seen as someone who provides support and assistance
• Excellent verbal and written communication skills.
• Excellent presentation skills including the ability to speak before large audiences and prepare and provide PowerPoint presentations.
• Excellent computer skills including Microsoft Office; ability to learn new computer applications such as adverse event reporting software (RL6 Solutions).