JOB DESCRIPTION

Our Mission is to extend the healing ministry of Christ.

We are more than healthcare. We are a family of caregivers who see what we do as a calling and treat every person, every time as if they were a loved one. We don’t just heal what hurts. We ease minds and encourage spirits by providing a more personal level of care than ever before—physically, emotionally, and spiritually. Our mission is to Extend the Healing Ministry of Christ which starts with caring for others with uncommon compassion and going above and beyond to make those we serve, feel loved.

Wellness is at the core of what we do, focusing on living a better life today and always. We want everyone to Feel Whole and we see our work as a calling. This is how we make a difference. With our whole-person care, expertise and world-class resources we strive to provide an exceptional experience for all. With hospitals and facilities in over 9 states, our consistent approach to healthcare allows us to live our mission and ensure that our communities are living fuller, healthier lives.

GENERAL SUMMARY:

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. The position is respof9f9nsible for the overseeing the risk management program and assigned patient safety programs for the facility. This position is responsible for working in collaboration with the Chief Quality Officer in Patient Safety Organization, ensuring adherence to all federal regulations, medical staff bylaws and hospital policies. The position will report real and potential risk events in collaboration with Chief Quality Officer to the hospital Board of Directors or other governing body of the facility, administration, medical staff, hospital departments and committees as appropriate and as required by law. This position or their designee will systematically investigate all incidents/accidents/events that could lead to financial loss, this includes events related to general and professional liability, or as required by statute.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

• Develop, coordinate, and administer facility-wide systems for risk identification, investigation, and reduction. Assess all risks within the facility to include business risks, operational risks and clinical risk based on knowledge of national and state regulatory and accreditation standards and/or licensing requirements. Assess, develop, implement, and maintain educational risk management and loss control and/or quality of care programs for all personnel, including the facility’s Board of Directors on identified issues and any other related activities as statutorily required.

• Maintain working knowledge of CMS, Joint Commission or other national and/or federal standards such as required reporting of quality of care issues, Sentinel Events, corporate compliance related issues and any other requirements that directly impact the continued operation of the facility/entity. Ensures compliance with patient safety and risk management related standards by Joint Commission and other accrediting and regulatory entities, and participating in the clinical quality and safety efforts of the facility

• Works in collaboration with the Chief Quality Officer to ensure policies, procedures and data submission meets hospital and regulatory standards.

• Works in collaboration with medical staff leaders to ensure quality of care concerns are reviewed in adherence with medical staff bylaws and hospital policy.

• Receive and investigate reports of any serious event involving actual or potential injury to patients or visitors to assess liability and probability of legal action, including review of patient complaints that may be perceived as potential liability claims or litigious activities. Identify, investigate, and report on Joint Commission Sentinel Events and facilitate the Root Cause Analysis process as described in the Improving Organization Performance (PI) chapter in the most current published Joint Commission standards. Participate directly in the facility process for Disclosure of Unanticipated Outcomes.

• Coordinate and/or maintain the risk management implementation of on-line incident reporting into the AHS RiskMaster information system. Responsible for ensuring responses are received for risk events and routinely submitted to the Patient Safety Organization per policy. Responsible for training facility/entity staff to use the RiskMaster web-submission report form for event/incident reporting into the AHS RiskMaster database.

• Work in collaboration with the Corporate Risk Management as the facility liaison with AHS Claims Management and assigned defense counsel to coordinate the investigation, processing, and defense of claims against the facility; collect necessary information to assist with defense of claims including timely forwarding pre-suit notifications, summons and complaints to AHS Claims Management. Assist AHS Risk Management with facility-specific information and data queries necessary for renewal and placement of professional liability, general liability, workers’ compensation, motor vehicle, property, executive risk and other insurance coverages.

• Develops, maintains and updates risk management policy and procedures.

• Process and resolve formal patient grievances as defined by all applicable federal, state, and hospital accreditation regulations and/or standards.

• Quality and patient safety designee when leader is out of the hospital or needs additional support.

• Provides oversight of quality and safety committees, Clinical Improvement and Education team members,

KNOWLEDGE AND SKILLS REQUIRED:

• Able to act independently and demonstrate strong leadership, organizational skills, and problem solving abilities.
• Must demonstrate excellent interpersonal, verbal and written communication skills.
• Must have the ability to provide conflict resolution and fair negotiation skills when dealing with customers.
• Proficient in policy development and initiates programs and processes to ensure patient safety through risk/harm program reduction.
• Proficiency in preparing and presenting professional presentations is required.

KNOWLEDGE AND SKILLS PREFERRED:

• Advanced knowledge of communication skills to effectively investigate risk concerns.

EDUCATION AND EXPERIENCE REQUIRED:

• RN Nursing Degree
• Minimum of Bachelor’s degree in health-related field
• Minimum of five years’ healthcare experience

EDUCATION AND EXPERIENCE PREFERRED:

Minimum of two years of experience in health care risk management or equivalent preferred.

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

• Current RN State Licensure

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

• Certified Risk Management Professional (CRMP)

SUPERVISORY RESPONSIBILITIES

Assumes responsibility for department management in the absence of Chief Quality Officer.

Facilitates team huddles and activities

Provides input on annual evaluations

LIVING OUR SERVICE STANDARDS

How we treat those we serve and each other is what sets us apart from other healthcare organizations. We want everyone who walks through our doors to feel loved, cared for, and at ease. Whether you are clinical or non-clinical, your actions and behaviors can create an environment that either builds trust or causes anxiety and fear. We have made it easy for you to ensure that you are always building trust and providing excellent care by exhibiting our Service Standards.

All team members will be held accountable for consistently living out our 16 Service Standards and the additional behaviors listed below to ensure that every person, every time has an exceptional experience.

KEEP ME SAFE

I make safety my number one priority.

I protect privacy and confidentiality.

I keep my environment clean.

I follow the dress code and wear my badge correctly.

LOVE ME

I treat others with uncommon compassion.

I nurture whole-person care through CREATION Health.

I treat others with fairness and respect.

I listen and communicate using iCARE. (Introduce, Connect, Anticipate, Reinforce, Extend)

MAKE IT EASY

I help guests to their destination.

I speak highly of others to provide connected care.

I collaborate to create solutions, not excuses.

I innovate and continually seek ways to improve our work.

OWN IT

I am positive and aim to exceed all expectations.

I follow through on commitments.

I use discretion with personal devices.

I recover service and restore trust using ACT. (Acknowledge/Apologize, Correct, Thank)

Team members must conform to all AdventHealth organizational and departmental policies and procedures including but not limited to:

• Mission
• Vision
• Values
• Code of Conduct as outlined in the “Guidelines for Employees” handbook

Establishes and maintains a history of regular attendance; makes appropriate use of PDO and observes department call-in procedures for absence; establishes and maintains punctual work habits. Exhibits timely arrival and departure and dependable time habits including meal and other breaks.

Attends and participates in mandatory facility-wide and department training/meetings as required (including but not limited to: ALN, safety training, etc.). Is able to demonstrate and apply knowledge of fire, safety, security, and disaster procedure regulations as presented in orientation, outlined in the safety manual, and as pertains to each work area.

Required to respond to emergency situations (i.e. disasters, hurricanes, etc.) by reporting to department and staying until the crisis is over or your position is covered by incoming personnel. This is a mandatory requirement. Refusal to respond may result in termination.

Contributes to the successful achievement of department-stated goals and objectives and will facilitate staff cohesiveness and communication.

This position description reflects the general duties and responsibilities necessary to describe the principal functions of the job, as identified, and shall not be considered an exhaustive list of job responsibilities which may be inherent in the job. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. The responsibilities listed may be subject to change at any time and individuals may be asked to perform duties outside of their regular responsibilities to support the ongoing operations of AdventHealth and its facilities.

I have read and understand this job description.

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Employee Signature Date

External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job specific responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case by case basis. If the requirement is not marked, then the standard is generally considered not applicable.