Director of Risk, Safety and Compliance

Job Summary:  

The Hospital Risk, Safety & Compliance Officer is responsible for developing, implementing, and overseeing programs that ensure patient, staff, and visitor safety while protecting the organization from legal, regulatory, operational, and clinical risks. This position leads efforts to maintain compliance with healthcare regulations, accreditation standards, and internal policies. The officer collaborates with clinical and administrative leaders to foster a culture of safety, transparency, and continuous improvement across the PRMC organization.

Key Responsibilities

1. Risk Management

• Identify, assess, and evaluate clinical and operational risks throughout the hospital.

• Oversee the incident reporting process, conduct root-cause analyses, and track corrective actions.

• Maintain risk management databases and prepare risk trend reports for leadership.

• Support claim investigations, liaising with legal, insurance, and third-party partners.

• Recommend risk mitigation strategies and monitor their effectiveness.

2. Patient & Staff Safety

• Develop, implement, and monitor hospital-wide safety policies and procedures.

• Lead safety rounds and audits to ensure a safe physical environment.

• Coordinate emergency preparedness programs, including disaster drills and response plans.

• Provide training on safety practices, including infection control, hazardous materials, and workplace injury prevention.

• Ensure compliance with OSHA, CMS, Joint Commission, and other relevant safety standards.

3. Regulatory Compliance

• Ensure the hospital meets all federal, state, and local regulatory requirements.

• Monitor compliance with accreditation standards, including DNV and other regulatory bodies.

• Lead internal audits to assess adherence to policies, procedures, and documentation standards.

• Prepare and submit required reports, filings, and corrective action plans.

• Serve as the primary point of contact for regulatory inspections and surveys.

4. Policy Development & Quality Improvement Collaboration

• Develop, review, and update hospital policies related to risk, safety, and compliance.

• Work with Quality Improvement teams on initiatives that reduce harm, improve outcomes, and enhance patient experience.

• Use data analytics to identify trends and implement performance improvement interventions.

• Promote a culture of continuous learning and regulatory readiness.

5. Training & Education

• Conduct regular staff education on risk management, safety protocols, and compliance standards.

• Develop training materials and competency assessments.

• Support new employee orientation on safety and compliance expectations.

Qualifications

• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field 

• Strong knowledge of healthcare regulatory requirements (CMS, DNV, OSHA, HIPAA, state health codes).

• Excellent analytical, investigative, and problem-solving skills.

• Strong interpersonal and communication abilities with the capacity to collaborate across departments.

• Ability to manage sensitive information with discretion.

Benefits / Compensation: 

Competitive wages and excellent fringe benefit program.  Salary commensurate with experience.   

BenefitsEEssEssennd Responsibilities include the following: Other duties may be assigned.BB

ï‚· Adheres to Simply The Best Standards of Performance.

ï‚· Establish appropriate structures and processes in relation to risk reporting, incident

management and Health and Safety within the Hospital.

ï‚· Review the Hospitals Safety Statement and related policies/procedures/guidelines, in

consultation with relevant personnel and with due regard to prevailing legislation, and

make recommendations to the CNO as considered necessary.

ï‚· Coordinate the development and review of relevant/required risk and incident

management policies, procedures and guidelines.

ï‚· In conjunction with appropriate staff, assist in identification of potential risk through risk

assessment, analysis of accidents/incidents and near miss incidents, periodic safety

inspections and/or audits. Make recommendations to reduce, prevent or eliminate risks

identified.

ï‚· Maintain a risk audit database and liaise with department heads in relation to issues

arising.

ï‚· Enter all accidents/incidents/near miss incidents onto QDC or other incident tracking

computer database and generate reports.

ï‚· Coordinate the claims management function.

ï‚· Prepares reports and statistical data for the QA committee, medical staff committees,

medical executive committee and the facility's administration and other committees as

needed in an accurate, concise, and timely manner leveraging all available technology.

ï‚· Liaise with the Hospital’s external Safety Consultants on all aspects of Health, Safety

    
 iinr