Manager Patient Safety Clinical Risk

Job Description

Responsible for collecting and investigating collaboratively all grievances and occurrence reports reported to the organization according to regulatory standards within appropriate time frames. Assists with development of action plans related to patient safety and clinical risk issues. Administrator of incident reporting system for Incident Reports and Patient Related Events. Tracks and trends reports including grievances, incident reports and legal filings including subpoenas and notice of intent. Provides reports to hospital committees including the Board. Serves on the survey response team. Ensures compliance with all applicable laws and regulations; working with leadership and staff to create policies and procedures that ensure good quality care and minimize harm to the patient; and constantly performing follow-up evaluations of data and organizational performance to ensure consistent improvement.

SHIFT AND SCHEDULE

Full Time: 8:00 AM – 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

Clinical Risk Management

• Conducts investigations into adverse events, safety events, and Root Cause Analyses, ensuring timely escalation of significant issues.
• Champions increased reporting of near misses, adverse events and serious safety events.
• Leads and formats all Root Cause Analysis and action planning teams to mitigate and minimize clinical risk for our patients and families.
• Assists in discovering the root cause for specific patient care trends and developing and implementing action plans to improve performance utilizing a nationally recognized framework.
• Collaborate effectively with stakeholders throughout the organization to improve work processes and improve quality of care and patient experience.
• Leads investigations as defined by accrediting agency, Texas Department of State Health Services (TDSHS), and the Centers for Medicare and Medicaid Services (CMS) per regulatory standards.
• Partners with Accreditation Specialist and team for successful regulatory surveys.
• Maintains expertise in risk management systems and event reporting systems utilizing nationally recognized evidence based practices.
• Assists with disclosure conversations and provides real-time coaching for providers, senior executives and staff as directed.
• Manages Quality-of-Care grievances, ensuring regulatory compliance and timely resolution.
• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars /workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certifications.
• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.

Patient Safety

• Supports High Reliability and Just Culture initiatives to enhance patient safety and the psychological safety of those involved in safety events.
• Assesses, investigates, and trends safety posts, escalating concerns as needed.
• Builds strong relationships with stakeholders, providing education and routine data.
• Conducts regular rounds to engage frontline staff and reinforce shared learnings.
• Leads patient safety initiatives and contributes to program development.
• Ensures compliance with project deadlines and regulatory standards.
• Active participation in Texas Hospital Association (THA) Patient Safety Organization or the PSO as defined by the organization.

Quality of Care Grievances

• Owns grievance investigations from inception to resolution, handling complex and sensitive cases.
• Drafts regulatory-compliant response letters.
• Ensures CMS compliance in grievance management.
• Utilizes complaint management systems to track and resolve grievances efficiently.
• Is responsible for constantly performing follow-up evaluations of data and organizational performance to ensure consistent improvement.
• Is responsible for supporting organizational programs and initiatives; including the organization’s strategic goals.

EDUCATION AND EXPERIENCE

• Must have a current license as a Registered Professional Nurse in the State of Texas
• Bachelor's degree in nursing, from an accredited college or university. Master’s degree preferred.
• Must have at least five (5) years of hands-on acute care clinical experience or equivalent.
• Previous experience with program implementation, preferred.
• At least one (1) year of experience with data management or one (1) year as a member of a quality committee is preferred.

Certification/Licensure:

• Nursing, clinical or other applicable license/certification is required and must be maintained throughout employment.
• Certification through a nationally recognized accreditation board in Patient Safety (CPPS) through Institute for Healthcare Improvement (IHI) is preferred, but must be obtained within 2 years of filling the Risk Manager Role or Certified Professional in Healthcare Risk Management (CPHRM) through ASHRM.

Skills or Special Abilities:

• Must be highly organized, self-motivated, and adaptable to high-pressure environments with the ability to pivot and change assignment focus based on needs.
• Must be able to excel at prioritizing tasks, working independently or in teams, and maintaining professionalism, confidentiality, and adherence to organizational standards.
• Must demonstrate strong analytical, investigative, and problem-solving skills.
• Must demonstrate good judgment and decision-making skills.
• Must be able to effectively collaborate with diverse stakeholders.
• Must consistently demonstrate commitment to Midland Memorial Mission and Values and High Reliability principles.
• Must be able to apply basic principles and tools of performance improvement to a wide range of problems.
• Language Skills:
• Able to read and interpret medical record documentation and Hospital policies and procedures.
• Able to communicate effectively with patients, families, hospital staff, medical staff and the general public.

PHYSICAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to:

• Stand, walk, sit, stoop, reach, lift, see, speak and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff. The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.

SUPERVISION REQUIREMENTS

• No supervision of others is required.