TITLE: Director of Risk Management and Patient Safety
REPORTS TO POSITION: Chief Quality & Safety Officer
DEPARTMENT: Quality & Safety
OUR VISION: Creating America’s 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: Safety and Quality at St. Charles provides services which promote the physical and psychological safety of patients, visitors, and caregivers in our multi-hospital health system. Services include risk assessment, plan development and implementation, safety and policy / procedure management, and proactive process improvement to prevent harm and improve outcomes.
POSITION OVERVIEW: Under the direction of the SCHS Chief Quality and Safety Officer (CQSO), the Director for Risk Management and Patient Safety (DRMPS) will manage the daily operations of the organization-wide clinical Risk Management and Patient Safety programs. This position provides direct oversight of the departmental staff while providing guidance to clinical staff across the system. The DRMPS will develop and maintain systems within the organization to detect, monitor, prevent, organize, measure, investigate, report and manage patient adverse events, incident reports and other indicators of potential patient harm. The DRMPS shall also have an indirect reporting relationship with the SCHS Legal Department on management of all malpractice claims. SCHS aims to achieve our True North goals through improving health outcomes, increasing patient and caregiver safety and reducing preventable error in health care processes.
ESSENTIAL FUNCTIONS AND DUTIES:
Provide oversight to members of the Risk Management and Patient Safety department. This will include quarterly check-ins on performance, feedback and coaching.
Develop orientation and training curriculum for Risk Management and Patient Safety staff to ensure they’re capable and confident in achieving program goals.
Implement and manage a clearly-defined 24/7 risk management program to support clinical operations, including staffing for a 24/7 duty phone.
Assist the CQSO with maintaining and managing departmental financial goals for the department cost centers with clear focus on the True North goals of Affordability.
Manage the organization-wide Safety Alert System (Safety Event Reporting System) including, training and monitoring of proper use, monitoring events for immediate and longer term action, and trending and reporting of results that impact health system safety programs and initiatives.
In conjunction with Executive Leadership, respond to sentinel events and other serious safety events, and provide expert advice in the management and reporting of such events to administrative and clinical leadership and staff.
Conduct immediate/appropriate response to any serious safety event/complaint and serving as the primary health system representative and resource coordinator in interfacing with applicable patients, visitors, and/or caregivers. Monitor and take subsequent actions to assure learning, compliance and documentation.
Direct the investigation of all serious safety events, including sentinel events, under attorney client privilege when appropriate. Through the investigations, work closely with operations, medical staff, Legal and other key partners.
Facilitate and/or provide direction for the review of serious safety events using a consistent form of Root Cause Analysis and/or Failure Mode & Effects Analysis.
Meet regularly with hospital operations, medical staff and service line leaders to provide detailed reports on all serious safety events, claims and risk-related issues.
In collaboration with hospital operations, medical staff, quality management department and other key partners, disseminate lessons learned effectively throughout the health system, both inpatient and ambulatory.
Collaborate with hospital operations, medical staff and the quality management department to facilitate improvement plans identified through RCA and/or routine safety event reviews.
Keep up to date with new and revised state and federal statutes, regulations, and accreditation policies related to patient care. Review and evaluate related policies and procedures and recommend revisions as needed. Create for approval, new policies as needed.
Actively participate in a variety of committees within the health system as assigned.
Proactively evaluate areas of organizational clinical risk based on internal assessment and external benchmarking; and, implement strategies and policies, which promote patient and caregiver safety.
Analyze all statistical reports and advisories that identify risk management and patient safety patterns and trends for leadership, Medical Executive Committee, System Quality and Safety Council, and the Board Safety and Quality Committee.
Through an indirect reporting relationship with the Legal Department, oversee the coordination of all potential or actual claims with the third party claims administrator, outside counsel, and insurers.
Oversee the coordination of SCHS caregivers and counsel in preparation for discovery and litigation, ensuring that all privileges are protected and all potential evidence is properly sequestered.
Advise the Chief Legal & Risk Officer on issues impacting enterprise risk management and process improvement opportunities and initiatives.
In coordination with the Legal and Compliance Departments, as applicable, serve as liaison to external regulatory agencies for purposes of patient and physician reporting, event investigation and response, including Oregon Health Authority, Medical Board, Nursing Board, Board of Pharmacy and Joint Commission.
Responsible for budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control
Hires, directs, coaches and monitors the performance of all direct reports, to develop and maintain a high performance team that meets organizational and department goals
Monitors and ensure all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals
Provides and oversees team’s delivery of customer service in a manner that promotes goodwill, is timely, efficient and accurate.
Collaborates with teams to review processes and identify/implement opportunities for improvements, applying Value Improvement Practice concepts and tools.
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 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.
May perform additional duties of similar complexity within the organization, as required or assigned.
ADDITIONAL POSITION INFORMATION:
High energy, organized, persistent and creative individual with strong communications with all levels within the organization, interpersonal and systems thinking skills.
Ability to work collaboratively with other caregivers in a positive and effective manner.
Proven ability to management experience including a thorough understanding of lean/process improvement tools, behaviors and techniques, quality measurement and reporting, Joint Commission standards, Board of Registration in Medicine and OHA regulations, root cause analysis and preventive risk management strategies.
CPHRM a plus.
Microsoft Office, Google or related products required and experience in database management and systems development desired.
Knowledge of RL Solutions electronic event reporting product and data management systems.
Knowledge of Epic electronic medical records system.
Able to function effectively, independently, and efficiently in a stressful and dynamic work environment.
Required: Bachelor of Science in Nursing or other health related fields
Preferred: Master’s degree in Risk Management/Patient Safety or Nursing/Healthcare related field or JD preferred.
Required: Valid Oregon driver's license and ability to meet St. Charles Health System driving requirements.
Required: Minimum of 5 years’ experience in a leadership role within healthcare operations to include experience in a hospital or medical center dealing with regulatory, patient safety and/or clinical risk issues.
Internal Number: R1006588
About St Charles Health System
St. Charles Medical Center – Bend is a hospital in Bend, Oregon, United States. It is the largest hospital in Central Oregon, and a level 2 trauma center. St. Charles medical center [SCMC-B] is owned and operated by St. Charles Health System, Inc., a private, not-for-profit Oregon corporation.