• Job Description

  Req#: R1015915
  Typical salary range: $149,365 - $205,380/year
  
  Relocation to/Residence in Central Oregon required for this role. Paid relocation assistance provided for in-state or out-of-state candidates.
  Job Description
  ST. CHARLES HEALTH SYSTEM
  JOB DESCRIPTION
  TITLE: Director of Risk Management and Patient Safety
  REPORTS TO POSITION: VP, Chief Nursing Executive (with indirect reporting relationship to SVP/Chief Legal & Risk Officer relating to enterprise risk management and claims management)
  DEPARTMENT: Quality & Safety
  DATE LAST REVIEWED: August 2023
  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, clinical quality data and proactive process improvement to prevent harm and improve outcomes.
  POSITION OVERVIEW: Under the direction of the St. Charles Health System Chief Nursing Executive (CNE), 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 and operational 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 to the SVP/Chief Legal & Risk Officer, and will assist, as requested by and under the direction of the St. Charles Health System (SCHS) Legal Department, in providing support for clinical- or safety-based claims and lawsuits. 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. This position directly manages caregivers in Quality and Safety.
  ESSENTIAL FUNCTIONS AND DUTIES:
  Oversee and implement the annual risk management and patient safety plan.
  
  Implements and manages a clearly defined 24/7 risk management program to support clinical operations, including staffing for a 24/7 duty phone.
  In collaboration with operational and clinical leaders, 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.
  Leads 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.
  Staffs the system Risk Management & Patient Safety Committee that ensures the oversight and monitoring of safety action plans, RCAs, and drives proactive performance improvement.
  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.
  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. Provides oversight to members of the Risk Management and Patient Safety department. 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.
  
  Leads the development, implementation, and analysis of the Culture of Safety survey for the system.
  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.
  Provides reports and analysis for risk management and patient safety patterns and trends to leadership including: Medical Executive Committee, System Safety and Quality Council, and the Board Safety and Quality Committee.
  Through an indirect reporting relationship with the SVP/Chief Legal & Risk Officer, will assist, as requested by and under the direction of the SCHS Legal Department, in providing support for clinical- or safety-based claims and lawsuits. This support may include 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. Management and direction of all demands and claims will be the responsibility of the SCHS Legal Department.
  Advises the SVP/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.
  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 Lean concepts and tools.
  Supports the vision, mission, and values of the organization in all respects.
  Supports 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.
  EDUCATION:
  Required: Bachelor’s degree in nursing or other health related field.
  Preferred: Master’s degree in nursing, healthcare risk management, public health, other health related field or JD.
  LICENSURE/CERTIFICATION/REGISTRATION:
  Required: Pursuant to clinical background (RN, PharmD, PT/OT/SLP, etc). Ability to travel to business functions/trainings/meetings and all SCHS worksites.
  Preferred: Certified Professional in Health Care Risk Management (CPHRM).
  EXPERIENCE:
  Required: Seven (7) years related healthcare experience. Two (2) years’ experience in a management role within healthcare operations to include experience in a hospital or medical center dealing with regulatory, patient safety and/or clinical risk issues.
  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:
  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.
  PHYSICAL REQUIREMENTS:
  Continually (75% or more): Standing and walking, keyboard operation, use of clear and audible speaking voice and the ability to hear normal speech level.
  Frequently (50%): Sitting, lifting/carrying/pushing, or pulling 1-25 pounds.
  Occasionally (25%): Bending, stooping/kneeling/crouching, reaching overhead, grasping/squeezing, ability to hear whispered speech level.
  Rarely (10%): Climbing stairs.
  Never (0%): Climbing ladder/stepstool, lifting/carrying/pushing or pulling 25-50 pounds, operation of a motor vehicle.
  Exposure to Elemental Factors
  Rarely (10%): Wet/slippery area, chemical solution.
  Never (0%): Heat, cold, noise, dust, vibration, uneven surface.
  Blood-Borne Pathogen (BBP) Exposure Category
  Risk for Exposure to BBP
  Schedule Weekly Hours:
  40
  Caregiver Type:
  Regular
  Shift:
  First Shift (United States of America)
  Is Exempt Position?
  Yes
  Job Family:
  DIRECTOR
  Scheduled Days of the Week:
  Monday-Friday
  Shift Start & End Time:
  8:00am-5:00pm

• About the company

  St. Charles Health System, Inc.

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