SUMMARY OF MAJOR FUNCTIONSUnder supervision of the Vice President of Quality, directs others within the hospital and physician practices in system and process improvements that support the reduction of medical errors and factors that contribute to unintended adverse patient outcomes. This role facilitates patient safety assessments and investigations; educates others in the organization on the system-based causes for medical error; consults with management, employees, and the medical staff on issues related to patient safety; ensures the implementation of strategies to enhance patient safety; and ensures that information about patient safety is shared throughout the organization through appropriate channels. Collaborates with other members of the healthcare team to achieve quality goals, identify risk issues, and implement corrective actions. Collaborate with System Risk Manager, assigned council as needed, professional liability insurance carrier, and Inland staff related to claims, depositions, and trials.
ESSENTIAL FUNCTIONS AND WORK ROLE RESPONSIBILITIESCLINICAL RISK MANAGEMENT FUNCTIONSResponsibilities and Expectations:Inland Risk Management Program - Oversees program design, content, and daily operations including:1. RL6 Incident Reporting.a. Analyze or assess risks & risk events for understanding Assists clinical leaders with analysis and corrective action related to event reports. Utilizes proven patient safety tools and strategies to integrate corrective actions with sustainable measures across the continuum of care as appropriate to increase effectiveness and quality of patient care. b. Evaluate whether mitigation/prevention strategies are sustained and effective.c. Participates in sharing of "lessons learned" stories from adverse events as well as successful initiatives throughout the organization.2. Ensures compliance with Maine State Sentinel Event reporting law, including:a. Coordination of Significant Event Assessment Team activities.b. Ensure timely filing of required state notices and reports.c. Preparation of Executive Summaries of Sentinel Event Root Cause Analysis and intense Reviews, prepares monthly Hospital Quality and Board Reports as needed. 3. Compliance with reporting requirements of the Safe Medical Device Act regarding the mandatory reporting of serious patient events involving medical devices, and the Food and Drug Administration Modernization Act (FDAMA) regarding Medical Device Tracking of Implantable devices.4. Claims-Identify and report all potential claims to appropriate entities; interface with Northern Light Health RM, collaborate with assigned council as needed, Northern Light Health legal services to manage claims against MO and providers (discovery, depositions, administrative actions etc.) 5.Attends mediation, depositions, and trials as Inland representation and staff support as directed by Vice President of Quality. 6.Oversees/conducts staff education on Risk Management topics.QUALITY/PATIENT SAFETY FUNCTIONSResponsibilities and Expectations:1. Utilizes proven communication techniques to facilitate performance improvement and change. 2. Knowledgeable of current CMS requirements ensuring changes are communicated and education provided3. Oversee and support Data Analyst with collection, documentation, and interpretation of clinical data related to performance improvement/regulatory requirements 4. Perform random Inter-rater reliability on chart abstracted measures done by Data Analyst and report accuracy to VP of Quality5. Abstractions and interpretation of data requiring clinical knowledge or complex measures6. Analyzes regulatory reports and communicates to appropriate members of Senior Leadership7. Responsible to oversee safety surveys such as: Leapfrog, t, HIIN 3.0 etc.a. Use information from Safety surveys to ensure facility is meeting guidelines and promotes best practice.8. Collaborates with leadership to mobilize work groups when necessary to improve systems that manage risk, improve quality and the effectiveness of services provided at Inland Hospital. 9. Participates in other System projects/committees, providing insight and knowledge on patient quality and safety issues, as needed.10. Communicates risk management, patient safety and quality improvement information to established Inland and EMHS committees.11. Partner with Northern Light Health to Conduct the Culture of Safety survey and analyzes and disseminates results; partners with specific areas on best ways to improve patient safety. 12. Works collaboratively with unit Directors to align PI plans with regulatory requirements, Northern Light Health initiatives, and National Patient Safety Goals.13. Works directly with Administration, Department Directors, and Medical Staff to identify and address areas requiring change or development. Assists with meeting regulatory and payer compliance.14. Participates in Performance Improvement activities as assignedPHYSICAL ENVIRONMENTGenerally pleasant work environment. PHYSICAL CRITERIA/EFFORTHearing and vision acuteness constantly required. No long periods of sitting and/orstanding required. Occasional stress and frustration exist.SAFETY1.Maintain a safe environment which includes knowing and understanding hospital and departmental policies and procedures.2.Report and directly address identified environmental hazards when appropriate.3.Report and directly address violations of patient safety policy and/or protocol when involved or observed.4. Complies with Inland Hospital Hand Hygiene Standards.5. Adheres to Inland Hospital Standards of Behavior.OCCUPATIONAL RISKSMinimal exposure to any type of occupational risks. Position does not involveexposure to blood, body fluids, or tissue.PROBABILITY AND CONSEQUENCES OF ERRORSLack of adherence to healthcare regulation can result in risk exposure to the hospitaland possible negative patient outcomes. Poor performance will be addressed according to established progressive disciplinary policies and procedures of Inland Hospital and Maine State Law.NUMBERS SUPERVISEDThis is a non-supervisory position.- MINIMUM REQUIREMENTS FOR THE JOBA registered nurse with previous risk management and/or performance improvement experience preferred. Past successes in a leadership position and positive role modeling preferred. Proficiency in medical record reviews. Impeccable attention to detail and commitment to seeing projects through to fruition. Experience in facilitating group thinking and analysis of systems for leading continuous process improvement throughout the organization desired. Demonstrated ability to communicate effectively to all members of the healthcare team; clinical and non-clinical EDUCATIONRegistered Nurse with a Bachelor Degree required. MSN preferred Process improvement or clinical background required. Maintains own professional growth and development and utilizes this knowledge to serve the needs of the organization.EXPERIENCERegistered Nurse with a minimum of 5 years experience in Quality / Safety and Risk management required; Knowledge of performance improvement processes and national patient safety initiatives required. Because this role will lead organization-wide process change related to patient safety and quality, previous formal or informal leadership experience is strongly preferred. SPECIAL KNOWLEDGE REQUIREDKnowledgeable about Federal and State healthcare regulations and current risk management practice including process improvement tools such as Root Cause Analysis, Plan Do Act Check or LEAN a plus. Position requires self-starter who takes initiative and able to manage multiple priorities. Must be able to effectively research, survey, comprehend, analyze, plan, organize, control, and communicate the activities of assigned responsibilities. CPHRM or CPHQ preferred.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.