DEPARTMENT SUMMARY: Safety and Quality at St. Charles Health System 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 St. Charles Health System 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 these 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 St. Charles Health System Legal Department in assisting Legal with analysis and case workup of all malpractice claims. St. Charles Health System 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:

Provides oversight to members of the Risk Management and Patient Safety departments. This will include quarterly check-ins on performance, feedback and coaching.

Develops orientation and training curriculum for Risk Management and Patient Safety staff to ensure they’re capable and confident in achieving program goals.

Implements and manages a clearly-defined 24/7 risk management program to support clinical operations, including staffing for a 24/7 duty phone.

Assists the CQSO with maintaining and managing departmental financial goals for the department cost centers with clear focus on the True North goals of Affordability.

Manages 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, responds to sentinel events and other serious safety events, and provides expert advice in the management and reporting of such events to administrative and clinical leadership and staff.

Conducts immediate/appropriate response to any serious safety event/complaint and serves as the primary health system representative and resource coordinator in interfacing with applicable patients, visitors, and/or caregivers. Monitors and takes subsequent actions to assure learning, compliance and documentation.

Directs 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.

Facilitates and/or provides direction for the review of serious safety events using a consistent form of Root Cause Analysis and/or Failure Mode & Effects Analysis.

Meets 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, disseminates lessons learned effectively throughout the health system, both inpatient and ambulatory.

Collaborates with hospital operations, medical staff and the quality management department to facilitate improvement plans identified through RCA and/or routine safety event reviews.

Keeps up to date with new and revised state and federal statutes, regulations, and accreditation policies related to patient care. Reviews and evaluates related policies and procedures and recommend revisions as needed. Creates for approval, new policies as needed.

Actively participates in a variety of committees within the health system as assigned.

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

Analyzes 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, partners with Legal in the administration of all potential or actual claims and assists Legal in liaising with the third party claims administrator, outside counsel, and insurers.

Oversees 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.    

Advises 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, serves 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 ensures 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.