ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: RN Patient Safety Risk Manager

REPORTS TO POSITION: Director of Perioperative Services

DEPARTMENT: Perioperative/Perianesthesia Ser

DATE LAST REVIEWED: November 24, 2020

OUR VISION: Creating Americas healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENT SUMMARY: The Risk Management and Patient Safety Department protects and enhances clinical services, patient, employee, and visitor safety associated with the health system operations, through the development and implementation of a clinical risk management and patient safety program that mitigates risk and promotes patient safety improvement and compliance with applicable clinical standards and best practices to promote a Just Culture in the organization. The department works in collaboration with legal, claims, quality, safety and entity leadership.

POSITION OVERVIEW: The RN Patient Safety Risk Manager 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 Patient Safety Risk Manager 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 Patient Safety Risk Manager 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 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 harm 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 CAN 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 bets practices and evidenced based medicine.

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

Supports Value Improvement Practice (VIP- Lean) principles 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 organizations 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 of Science in Nursing.

Preferred: Masters Degree preferred, preferably in a health related field.

LICENSURE/CERTIFICATION/REGISTRATION

Required: Current RN licensure with the Oregon State Board of Nursing. Valid Oregon drivers license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites required. Certified Professional in Health Care Risk Management (CPHRM) required within one year of employment.

EXPERIENCE

Required: Three (3) to five (5) years experience in healthcare risk management and/or patient safety at a health system, hospital, or other health care facility. Proficient in using a safety alert reporting system and conducting Root Cause Analysis (RCA).

Preferred: N/A

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION:

Skills:

General:

Excellent communication skills and ability to interact with a diverse population and professional represent SCHS.

Ability to effectively interact and communicate with all levels within SCHS and external customers, potential employees.

Strong team working and collaborative skills.

Ability to effectively reach consensus with a diverse populations with differing needs.

Ability to manage facilitation and consensus building among healthcare professionals and agencies and achieve expected results.

Ability to multi-task and work independently.

Attention to detail.

Ability to adapt to multiple changing priorities including handle crisis situations effectively.

Knowledge of medical professional staff by-laws, peer review protection and governing board issues.

Knowledge of insurance and loss control theory and processing of professional liability/medical malpractice claims management.

Possess ability to identify and analyze problems collect data, establish facts, timelines and draw valid conclusions.

Possess knowledge of frisk identification and prevention techniques.

Possess critical thinking skills.

Ability to use independent judgment and to manage and impart confidential information.

PHYSICAL REQUIREMENTS

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing. Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level. Exposure to Elemental Factors

Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category: No Risk for Exposure to BBP

Schedule Weekly Hours:

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