JOB TITLE: Risk and Patient Safety Manager/RN
DEPARTMENT: Quality Management
REPORTS TO: Quality Management Director

• ONSITE POSITION; REMOTE NOT AVAILABLE

JOB SUMMARY
The Risk and Patient Safety Manager/RN is responsible for assisting the Quality Management (QM) Director with organizational risk management and patient safety initiatives. This role will support all departments in activities related to risk management and patient safety. This position is responsible for activities involving incident investigation, evaluation of patient safety events, claims or potential claims, property loss, and risk identification. Data analysis will be utilized to identify patterns or trends that need to be addressed through proactive performance improvement activities and action plan development. The Risk and Patient Safety Manager is an active partner with operational leaders in the development of actions plans and PI initiatives to improve patient safety and health outcomes.

JOB REQUIREMENTS

• Current, active license as a Registered Nurse in the State of Wyoming required.
• Bachelor of Science in Nursing (BSN) required; master’s degree or higher preferred
• Preferred Qualifications:
  • Training or experience in LEAN methodologies, Performance Improvement, Risk Management and Patient Safety

EXPERIENCE
At least five years of experience in healthcare OR equivalent combination of education and experience. Has a working knowledge of current hospital concepts in risk management, patient safety, performance improvement and regulatory requirements. Experience preparing and maintaining records and writing reports.

SKILLS

• Must possess a high degree of confidentiality in all matters with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
• Must have strong interpersonal skills with the ability to communicate with staff and public in a friendly, courteous and helpful manner.
• Must be able to interact effectively with a wide variety of people.
• Must have ability to perform effectively in highly stressful situations.
• Ability to apply critical thinking in various situations.
• Must be self-directed, motivated, and organized, with the ability to prioritize multiple tasks based on organizational needs.
• Must be able to collect, organize and evaluate data to present to others.
• Must have knowledge of the operations of the health care industry and the health care delivery systems.
• Must have well-developed verbal and written communication skills.
• Strong computer and keyboarding skills.
• Must be proficient in the use of Microsoft Office Suite products including Word, Excel, Outlook and PowerPoint.
• Ability to learn new computer software applications.

REQUIRED CERTIFICATIONS
Certified Professional in Health Care Risk Management (CPHRM) or ability to obtain within one (1) year of hire.

ESSENTIAL FUNCTIONS

• Possesses knowledge of Continuous Quality Improvement principles and supports the hospital’s philosophy of performance improvement. Participate on Quality Improvement teams as directed by the QM Director and will lead a minimum of two patient safety performance improvement projects/year.
• Oversee the organization’s event reporting program. Serves as system administrator for the event reporting program.
• Analyzes data and identifies trends or patterns. Collaborates with hospital leaders in the creation and implementation of action plans to address identified trends. The Risk and Patient Safety Manager will be responsible for working collaboratively with hospital leaders to ensure action plans are addressing the concerns and are completed timely.
• Under the direction of the QM Director, participates in monitoring activities to support compliance to state and federal regulations related to risk management and patient safety.
• Responsible for the coordination and implementation of the organization’s adverse event investigation program. Serves as a facilitator for Root Cause Analysis (RCA) or Sentinel Event investigations. Documents findings, actions and tracks action plans to completion. Maintains all documents related to adverse events. Communicates to QM Director and Senior Leadership any event, which may require reporting to Local, State or Federal agencies.
• As a member of the Quality Management Department, will facilitate and/or participate in departmental functions including but not limited to organizational LEAN or other quality improvement teams, work groups, and other quality management projects as assigned.
• As assigned by the QM Director, will be responsible for completion of risk management, patient safety or quality improvement projects with outside organizations such as Yellowstone Insurance Exchange, Quality Improvement Organizations (QIOs), Medicare Beneficiary Quality Improvement Project (MBQIP), Quality Health Indicators (QHi), etc.
• Collaborate with department leaders to maximize the organization’s participation and success with outside organizations dedicated to improving patient safety and reduction or mitigation of risk.
• Maintains up to date knowledge of regulations and standards regarding risk management and patient safety.
• Serves as a resource to the organization’s leaders, employees and Medical Staff regarding issues, questions or concerns related to risk management and patient safety.
• At the direction of the QM Director, acts as a liaison with outside agencies providing information, managing routine inquiries, etc.
• Prepares, at least annually, statistical reports, loss/expense summaries and claims data summaries which may identify trends impacting the delivery of safe patient care.
• Works with the QM Director to identify cases which have actual or potential risk to the organization as a medical malpractice claim and communicates actual/potential claims to appropriate insurers and Administration. Assists the QM Director with claims management through the monitoring of claims resolution. Maintains files for potential/actual claims through resolution and closure.
• Completes chart review for identification of cases with potential/actual risk management or patient safety concerns. Communicates with the QM Director any cases identified for possible referral through the organization’s peer review process.
• Provides education to leaders, employees and the Medical Staff on pertinent risk management and patient safety topics.
• Manages the organization’s patient complaint and grievance program. Works with leaders, Medical Staff, QM Director and Administration to ensure timely investigation and follow up to complaints/concerns reported by patients or their family/representative. Maintains complaint log, analyzes complaint/grievance data and reports to leaders as directed. Works with the QM Director to draft appropriate communication back to the patient/family/representative.
• Compiles and submits reports to appropriate committees on risk management and patient safety trends. These reports will be shared with the QM Director prior to presenting them to committee.
• Assists with the review, revision and development of policies and procedures related to risk management and patient safety activities.
• At the direction of the QM Director, may be required to assist with chart abstraction and submission of required reporting measures to CMS or other regulatory bodies.