Director of Patient Safety and Risk Management

Job Description

Job Description

POSITION FUNCTION/OVERVIEW:

The Director of Patient Safety and Risk evaluates events, patterns/trends, keeps appropriate leadership informed of events along with recommendations to reduce such events. The structure and functions of the Hospital Risk & Patient Safety Program are designed to comply with guidelines and standards of TJS, AHCA and DCF.

PRIMARY DUTIES/RESPONSIBILITIES:

• Disseminates trends to executive management, Performance Improvement Committee, and department heads identifying successes and areas for improvement.
• Conducts comprehensive annual gap analyses using internal data, regulatory standards, accreditation requirements, and industry best practices to evaluate the effectiveness of patient safety and risk management programs.
• Prepares clear, data-driven reports and professional presentations for Performance Improvement Committee meetings, translating findings into actionable recommendations to mitigate organizational and clinical risk.
• Develops and prepares the annual risk assessment and corresponding performance improvement plan, utilizing incident data, audit results, grievances, and trend analyses to support the organization’s Continuous Quality Improvement (CQI) plan. Including, Anti-Ligature Assessment.
• Provides training in Risk Management and Patient Safety at new employee orientation and annually thereafter.
• Collects, reviews, and analyzes data, reports, and relevant medical records to support timely investigation and resolution of internal incidents.
• Prepares responses to insurance audits, incident follow-up inquiries, and requests for information from regulatory agencies or other external entities related to patient safety and risk.
• Reviews, tracks, and maintains all hospital Incident Reports to ensure accuracy, completeness, timeliness, and appropriate categorization, and confirms corrective actions are documented and completed.
• Analyzes incident, grievance, and audit data to identify trends and emerging risks, producing comprehensive monthly dashboards and summary reports for Leadership Team review.
• Oversees and maintains all hospital grievances, ensuring they are logged, investigated, and resolved in compliance with regulatory, accreditation, and organizational requirements.
  • Meet with patients within the appropriate timeframe to ensure investigation is initiated.
  • Collaborate with departments/directors to ensure appropriate response.
  • Analyze results, create monthly reports for Leadership team review.
• Collaborates closely with department directors, medical staff, and interdisciplinary teams to ensure appropriate corrective actions, risk mitigation strategies, and sustainable improvements are implemented.
• Monitors the effectiveness of corrective action plans through follow-up audits and data review, modifying strategies as needed to reduce risk and strengthen the organization’s culture of safety.
• Participates in Emergency Management preparedness activities, including development, review. Involvement in drills, exercises, and after-action reviews; and collaboration with leadership and department heads to identify risks, gaps, and corrective actions.
• Responsible for oversight of the Security Department.
  • Work collaboratively with the Security Supervisor to ensure adequate coverage, evaluation of security staff. Participate in onboarding and termination of security staff.
• Performs other duties as assigned, consistent with the scope and responsibilities of the Director of Patient Safety and Risk role, to support organizational priorities, regulatory compliance, and continuous improvement.

QUALIFICATIONS REQUIRED:

• Bachelor's Degree, Preferred.
• Two years current experience in Risk Management or Two years of college with a minimum of two-three years’ experience in Risk Management in a healthcare or mental health setting.
• Knowledge of the TJC (The Joint Commission) Standards and Patient Safety requirements.
• CPR and AED Certification

SKILLS:

• Knowledge of patient safety principles, risk management practices, and adverse event prevention within hospital or healthcare settings.
• Strong understanding of regulatory and accreditation standards, including CMS Conditions of Participation, Joint Commission requirements, AHCA/state regulations, and insurance audit expectations.
• Proficiency in developing gap analyses, enterprise risk assessments, corrective action plans, and Continuous Quality Improvement (CQI) initiatives.
• Exceptional written and verbal communication skills, including the ability to prepare clear reports, executive summaries, and professional presentations for leadership committees and governing bodies.
• Competence in emergency management preparedness, including participation in hazard vulnerability analyses (HVA), emergency operations planning, drills, and after-action evaluations.
• High level of organizational and time-management skills, with the ability to manage multiple priorities, deadlines, and competing demands across hospital locations.
• Proficiency with incident reporting systems, electronic health records, and data reporting tools to support accurate documentation and timely analysis.
• Strong critical thinking, problem-solving, and decision-making skills, with a proactive and solutions-focused approach to risk mitigation.
• Ability to function independently while exercising sound judgment and accountability in a senior leadership role.
• Experience managing confidential and sensitive information with professionalism, integrity, and compliance with HIPAA and organizational policies.
• Ability to lead education and training programs on risk management, patient safety, just culture, and reporting expectations for diverse staff audiences.
• Strong interpersonal and collaboration skills to work effectively with executive leadership, medical staff, department directors, frontline staff, patients, and families.

Proficiency in developing gap analyses, enterprise risk assessments, corrective action plans, and Continuous Quality Improvement (CQI) initiatives.