POSITION SUMMARY:Â Works as a salaried employee in accordance with the established policies as outlined in the Personnel (Employee) Handbook.Â Expected to give a minimum of thirty (30) days notice prior to voluntary resignation.Â A probationary period of one hundred eighty (180) days is required.Â The work area is wholly within the designated hospital area.
DUTIES AND RESPONSIBILITIES:Â
Risk identification and Evaluation
Ensures appropriate and timely reporting of occurrences by maintaining a Healthcare Peer Review Reporting system (Occurrence notification system);
Collects and screens all reports.
Enters incidents into the MIDAS Database.
Analyzes and trends data
Identifies actual and potential risk situations and facilitates the determination of causative factors
Refers occurrences for followâ€'up to appropriate department or medical committee; ensures that all Level III/IV are referred to the Peer Review Committee
Receives immediate and concurrent reporting of adverse patient outcomes identified by the PI process
Performs risk surveys and inspects patient care areas in concert with hospital's safety (EOC) program committee objectives
Reviews reports on facility and equipment to assess loss potential
Receives and investigates reports of product problem to determine appropriate response and establish record keeping responsibilities. In the event of patient injury, established direction from Corporate Risk Management in the appropriate action for defense strategy
Receives information (verbally or formally on the HPR) from facility staff regarding patient events, which may lead to a claim.
Networks with department managers to implement system changes aimed at optimally reducing or eliminating causative factors.
Interfaces with Performance Improvement Director specific to provision of patient care, and assessment of quality data
Networks with medical staff to ensure active involvement and participation in:
Risk reduction/loss prevention problem solving and program development designed to benefit the clinical aspects of patient care and safety
Networks with medical staff to ensure the credentialing and privilege delineating process requires information regarding professional liability experience, results of peer review activities, changes in medical staff memberships, clinical privileges, licensure, etc.
Interfaces with the Patient Advocate specific to patient complaints and assesses/recommends action, on those, which may be a source of potential litigation.
In conjunction with hospital administration recommends actions when possible to resolve with patient and/or family any grievances against hospital perceived as potential liability claims.
Refers policies that present particular risk in relation to previously identified problems to Corporate Risk Management
Identifies particular practices having legal connotations to target planning of preventive and corrective measures
Assesses liability and probability of legal action
Is available to resolve treatment issues, including patient refusal of treatment, consent issues, HIPPA
Assists Administration in preparing contracts for approval
With assistance from Corporate Risk Management provides advice on contract language necessary to fulfill insurance and Risk Management requirements
Evaluates each contract negotiated by the hospital with assistance from Corporate Risk Management when needed to ensure that insurance and liability losses are adequately addressed and that risk is transferred to other party responsible
Assists Administrator in facilitating the processing of summons and complaints served on the hospital and its employees.
Reports receipt of summons and complaints immediately to Corporate Risk Management and Insurance Department.
Assists the Corporate Risk Management as needed to intervene, document and assist in the investigation of all claims.
Coordinates investigation of claims within the facility:
Directs inâ€'house claims investigation.
Preserves all pertinent information (medical record, x-rays, equipment, lab/pathology specimens, relevant reports/d policies and procedures).
Facilitates early reporting
Establishes early control of situation
Assists in obtaining materials for attorneys
Maintains all legal case files and ensures maximum protection and discoverability
Coordinates with and assists attorneys as they interface with the facility and employees.
Advises Business Office of actions consistent with directions from Corporate Office for unpaid accounts involved in litigation
Loss Control and Prevention
Conducts/facilitates in-services to educate employees and physicians
Participates in developing/reviewing policies and procedures
Operates to maintain and facilitate system securing hospital, employee and patient property.
Facilitates, develops, and provides educational programs to insure all employees and medical staff are aware of the Risk Management concept and its relation to their specific duties/job role in identifying and reducing liability exposures.
Plans and presents risk management information to all new employees at hospital orientation.
Plans and presents Risk Management information to all employees at annual update.
Plans, presents, facilitates, and/or recommends in-services to all departments as necessary to address Risk Management problems
Submits articles to hospital, nursing, medical staff newsletters, as appropriate
Plans and presents in-services/information at Department Managers meetings. Provides Risk Manager presentation specific to management levels at least annually
Shares current literature and articles of relevance with all appropriate departments
Plans, facilitates, presents information and suggests topics on Risk Management to Committees or hospital departments as necessary and based upon occurrences
Reporting, Report Preparation and Submission
Provides aggregate analysis of risk data and trend analysis of incidents to:
Corporate Risk Management
Patient Safety Council
Environment of Care/Safety Committee (Safety related only)
Medical Staff Committees/Department as necessary and related to the department
Directly reports to Administration those incidents with claims potential.
Reports to Corporate Risk Management any serious risk event involving actual or potential injury to patients and visitors; enters PCRâ€™s (Level III/IV incidents) into the STARS Database within 10 business days of the incident.
Advises the Medical Director and Medical Executive Committee as needed
Serves as a resource to the Medical Staff Credentialing Process and the Credentials Committee as needed.
Data from physician peer review and risk management activities are utilized in the decision making process of granting privileges to and reappointment of medical and allied health staff.
Develops, coordinates, presents/facilitates educational programs specific to medical staff concerns.
Submits articles appropriate for the Medical Staff newsletter
Advises physicians on issues of interest or concern including Informed Consent process; Documentation and communication; Accountability; Response to patient/family complaints; and internal problem solving
Provides methods to communicate patient events to the Risk Manager that may result in a claim
Assists in oversight of Regulatory Agency compliance standards
Coordinates survey readiness activities with all departments
Coordinates and provides oversight in completion of improvement/action plans
Provides correspondence to Regulatory Agencies as required
Advises Senior Team members and providers on standard changes/updates