Patient Safety Risk Manager

: The RN provides leadership for the design, implementation and coordination of the organization wide Risk Management and Patient Safety program across the facilities and service areas within St. Charles Health System with the objective of maintaining patient safety. The RN develops, coordinates, and facilitates implementation of effective systems for risk identification, investigation, and mitigation of both potential and actual patient safety concerns and risks. This position promotes and facilitates the transition from a retrospective and reactive model of risk management to a prospective and proactive approach for patient safety models consistent with the concepts expected of Enterprise Risk Management (ERM) and a High Reliability Organization (HRO). The RN serves as Subject Matter Expert for Root Cause Analysis, Safety Culture, National Patient Safety Goals, and other evidence-based programs as needed. This position is responsible for reviewing policy operational changes and making recommendations to the Director of Risk Management and Patient Safety. This position does not directly manage any other caregivers.

Essential Functions And Duties

Maintains oversight of the Safety Alert System (SAS) reporting and response process, including severity rating and evaluation of all safety events, the investigation and identification of risk exposures; risk analysis using selected tools, RCA and apparent cause analysis; risk evaluation and monitoring using algorithms and review criteria; and risk treatment including establishing a potential claim file, working with medical malpractice and general liability carriers follow-up and performance of trending analysis for assigned facilities/service areas. Stops the line to mitigate potential patient safety conditions and maximize learning.

Facilitates cross-functional/site process improvement endeavors to support elimination of errors and other factors that contribute to potential or actual adverse patient outcomes.

Uses trends obtained from safety reports, patient safety rounds and other sources of patient safety data to focus on areas for further analysis, risk management, patient safety, and loss prevention activities.

Identifies potential and actual sentinel events or serious safety events with prompt notification and debrief to key stakeholders including senior leadership, and site administration for conducting investigation of event and root cause analysis.

Leads investigation for a Sentinel or serious safety event investigation and analysis. Leads RCA process and failure effect mode analysis (FMEA) to identify opportunities for system and process improvements. Supports the preparation of documents for reporting serious harm events to State and accreditation agencies.

Develops and provides education/communication to leadership, physicians, colleagues and other stakeholders on patient safety needs, initiatives, activities, and for shared learning. Participates in assigned Medical Staff and Hospital Quality and Safety Committees.

Proactively performs surveillance and evaluates patient safety risks in a uniform and consistent manner for assigned facilities, service areas and affiliated joint ventures.

Collaborates with internal legal counsel to support their investigation and defense of claims against the Health System. Provides external defense attorneys requested information to prepare for pending litigation and/or claim review. Prepares and submits PCE (potentially compensable event) reports for potential claims.

Provides caregiver and provider guidance and support for patient care issues with patient safety/risk or legal implications, i.e. consent issues. Works in collaboration with the compliance department for potential EMTALA and HIPAA violations.

Provides guidance to leadership as to acceptable bill adjustments under CMS stipulations. Initiates bill adjustments to mitigate potential claims in collaboration with claims management and in congruence with policy and CMS limitations.

Reviews and supports the completeness of patient complaint and grievance response letters.

Provides guidance to caregivers and providers for disclosure of unanticipated events to patient and their families.

Proactively conducts failure mode and effect analysis for high risk or problematic care processes across System facilities and joint venture businesses, at minimum as required by The Joint Commission for continued accreditation.

Provides for 24/7 Patient Safety/Risk Management coverage and response for assigned areas of responsibility.

Collaborates with Subject Matter Experts to develop and spread learnings via Safety Alerts, Advisories, and key learnings based on best practices and evidenced based medicine.

Refers clinicians and caregivers to Critical Incident Stress Management (CISM) when appropriate. Understands the basic model of event management and being sensitive to frontline caregiver emotional needs.

Supports the vision, mission, and values of the organization in all respects.

Supports lean with goal of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients, and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

Education

Required: Bachelor’s degree in related field.

Preferred: Master’s Degree in related field.

Licensure/Certification/Registration

Required: Current Oregon RN license. Ability to travel to business functions/trainings/meetings and all SCHS worksites required. Certified Professional in Health Care Risk Management (CPHRM) required within three years of employment or Certified Professional in Patient Safety (CPPS) within two years

Preferred: Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Risk Management (CPHRM.

Experience

Required: Three years experience with direct patient care. at a health system, hospital, or other health care facility. Use of an occurrence reporting system and Microsoft Excel, PowerPoint and Word programs.

Preferred: Three years experience in quality, regulatory, healthcare risk management and/or patient safety at a health system, hospital, or other health care facility. Proficient in use of an occurrence reporting system and Microsoft Excel.