Director of Risk Management

• Masters degree in healthcarerelated field or JD required.

• CPHRM is required within 6 months of hire CPPS preferred CPHQ optional.

• At least 5 years of direct clinical care and 5 or more years of progressive leadership in risk or quality required

• Requires strong organizational skills persistence creativity and strong communication interpersonal and systems thinking skills

• Excellent verbal and written communication skills.

The Director of Risk Management oversees the operation Risk Management and Patient Safety programs and provides guidance to clinical staff. The Director will develop and maintain systto detect monitor prevent organize measure investigate report and manage patient adverse events malpractice claims safety reports (RLs) and other indicators of potential patient harm.

Position: Director of Risk Management

Department: Risk Management

Schedule: Full Time

The Director responds in a timely fashion to patient harm events learns from individual cases identifies risk trends and actively educates leaders administration clinicians and staff regarding methods to maximize patient safety and simultaneously reduce professional liability claims.

• Directs the initial intake processes of adverse hospital and patient events and event reporting ensuring timely analysis and followup.

• Provides advice consultation and support to hospital and professional staff on clinical risk and ethical issues.

• Responds to sentinel events and other serious occurrences and provide expert advice in the management and reporting of such events to administrative and clinical leadership and staff.

• Oversees the investigation of patient/visitor incidents that have the potential for litigation and financial loss. Ensures that all information necessary to prepare for the analysis and defense of claims is collected and provided to the Director of Claims.

• Oversees and participates in the 24/7 oncall system of accessibility by staff to provide immediate consultation mitigation and recommendations in responding to adverse events.

• Actively participates in the Daily Safety Huddle and ensures there is daily risk management presence

• Directs investigations related to targeted incidents and adverse events including interviewing staff and reviewing medical records for evaluation of clinical data measurement of improvement and/or regulatory liability reporting.

• Proactively evaluates areas of organizational risk based on internal assessment and external benchmarking; and implements strategies and policies which promote patient and staff safety.

• Promotes the organizationwide online incident reporting process including trending and reporting results identification of problemprone areas and the facilitation of prevention initiatives.

• Actively engages with key stakeholders to resolve safety issues and trends that are identified at the Daily Safety Huddle and safety reports

• Collaborates with physician leadership on case reviews and the formal professional practice evaluation process

• In collaboration with our Captive leadership reviews cases and determines events that are appropriate for our CANDOR process

• Designs and presents educational programs on patient safety and risk management for all leaders employees and physicians. Assists clinical chairs and department chiefs to design risk management programs specific to their areas.

• Manages an electronic database for tracking patient safety events. Analyzes data to identify trends and opportunities to improve patient safety and report findings.

• Consistently exemplifies behaviors that support a strong culture of safety.

• Actively participates in the development revision and maintenance of policies needed to prevent or reduce loss exposure. Ensures policies and procedures meet all regulatory and accreditation requirements.

• Leads the review of serious occurrences requiring Collaborative Case Reviews or Failure Mode & Effects Analysis.

• Meets regularly with Executive and Medical Staff Leadership to provide detailed reports on all serious incidents claims and riskrelated issues.

• Develops risk management reports for the Boards senior management clinical leadership and external boards and agencies as appropriate. Prepares and presents reports cases benchmarking data and other educational information to the Claims Committee.

• Coordinates claims investigation medical record requests and legal defense processes.

• Serves as a liaison to external regulatory agencies for purposes of appropriate adverse event reporting to the Department of Public Health Board of Registration in Medicine FDA etc. and coordinates surveys by the Department of Public Health.

• Assists in the identification and development of information related to equipment failures to ensure compliance with the reporting requirements of the Safe Medical Devices Act. Submits related reports via MedSun.

• Keeps up to date with new and revised state and federal regulations and statutes BMC Bylaws and regulations and Safety Alerts related to hospital and patient care.

• Maintains ongoing awareness of rapidly evolving rules regulations and laws needed to keep BMC in compliance with all external stakeholder requirements.

• Tracks and trends Serious Reportable Events (SRE) and Adverse Events.

• Assists with the completion of BORM reporting requirements including but not limited to: Annual reports Semiannual reports Annual Disciplinary Reports and Safety and Quality Reports (SQRs).

• Updates the Patient Care Assessment Committee Plan annually.

• Respond to agency requests and create corrective action plans if needed.

• Oversight of onsite regulatory reviews including notification to leadership and providing written summary of events.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

• Masters degree in healthcarerelated field or JD required.

• CPHRM is required within 6 months of hire CPPS preferred CPHQ optional.

• At least 5 years of direct clinical care and 5 or more years of progressive leadership in risk or quality required

• Thorough understanding of QI processes tools and techniques quality measurement and reporting TJC standards Board of Registration in Medicine and Department of Public Health regulations Collaborative Case Reviews and preventive risk management strategies

• Requires strong organizational skills persistence creativity and strong communication interpersonal and systems thinking skills

• Confidentiality is imperative to the success of this role

• Must have interpersonal skills necessary to deal effectively with administrative and clinical leadership staff Clinical Chairpersons and other healthcare professionals

• Ability to effectively interview individuals and groups from diverse professional backgrounds

• Ability to collect event information and organize into a coherent narrative

• Highly selfmotivated. Ability to manage multiple projects simultaneously and adhere to work deadlines.

• Ability to inspire trust and be seen as someone who provides support and assistance

• Excellent verbal and written communication skills.

• Excellent presentation skills including the ability to speak before large audiences and prepare and provide PowerPoint presentations.

• Excellent computer skills including Microsoft Office; ability to learn new computer applications such as adverse event reporting software (RL6 Solutions).