Head of Risk Management & Audit

Director Of Risk Management
The Director of Risk Management is responsible for continual improvement in the quality, safety and satisfaction of care delivery at all Pipeline Health facilities; and works closely with the Executive Team, hospital leadership and hospital quality and risk department to develop, implement and manage the risk management and Patient Safety Programs in order to: 1) Improve patient care and outcomes, 2) Reduce the risk of adverse outcomes from patient care activities; 3) Monitor compliance with regulatory and accreditation requirements and standards; and 4) Reduce and/or mitigate risk of professional liability.
Frequent travel between the PLH facilities is required.
Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.
Essential Functions:

Maintains confidentiality by assuring security of confidential files and information and communicating only with those who have a need-to-know confidential information.
Uses critical thinking to investigate issues and process failures. Gathers facts before formulating opinions or action plans.
Surveys the Pipeline Health facilities with enough frequency to be 1) recognized as a supportive team member for staff, 2) a credible resource for regulatory, accreditation, and patient safety issues, 3) able to accurately represent Pipeline Health's needs related to patient safety, accreditation and regulatory issues to the Execute Team, and 4) able to timely recognize unfavorable trends and provide effective intervention.
Maintains goodwill in all investigations without assigning blame; preserves staff dignity.
Supports implementation of infection prevention standards; active participant of the EOC Committee.
Serves as a resource, when necessary, in assisting other departments/programs in developing their policies and procedures and patient safety initiatives.
Effectively negotiates to achieve resolution concerning risks, exposures, and standards deficiencies; utilizes facilitation techniques appropriately.
Effectively implements, monitors and manages a robust patient safety culture.
Evaluates the plans, policies and procedures, and process changes implemented as a result of risk management, patient safety, and quality management activities.
Develops and maintains collaborative relationships with key departments and committees as assigned.
Reports claim information on potential liability cases to General Counsel.
Develops a collaborative relationship throughout the organization to leverage resources to advance risk prevention and claims and litigation/professional liability lessons-learned programs.
Recommends appropriate revisions to new or existing policies, procedures, and forms to reduce risk and exposures.
Performs other related duties as assigned.
Risk and Patient Safety Management:

Develops, implements, and maintains an organizational risk management plan.
Develops, implements and maintains an organizational patient safety plan.
Administers a nationally approved survey on Patient Safety Culture at least once every 12 months and provides timely feedback to the Executive Team as directed.
Analyzes a wide variety of data (i.e., occurrences, complaints, surveys, etc.) to identify undesirable care, outcome, and process trends in order to assess the overall safety of care.
Develops, maintains and monitors routine risk management and patient safety data reports that capture outcomes, causes, interventions and barriers to safe patient care.
Recognizes process failures that are appropriate to refer to Performance Improvement/Quality for action.
Develops and provides an annual report on risk management and patient safety activities and data.
Uses critical thinking to investigate risks and exposures by gathering and formulating data based on facts, using timelines and other tools for investigating incidents and recreating events such as root cause analysis and FMEA.
Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, and medical staff improvement (e.g. OPPE, FPPE).
Facilitates investigations and management of timely submissions of patient and health plan grievances.
Serve as Pipeline Health's Safety Officer.
Regulatory/Accreditation Compliance:

Acts as a resource for compliance with requirements to report specific incidents to local, state, federal, and accrediting agencies.
Serves as the liaison between applicable government, regulatory, and key stakeholders and conducts facilitation of on-site visits and evaluations.
Maintains current knowledge regarding state licensure requirements for staff working in the Pipeline Health facilities.
Maintains current knowledge regarding all applicable standards and regulations of The Joint Commission (TJC) and HFAP (Healthcare Facilities Accreditation Program) necessary to maintain accreditation.
Recognizes and implements appropriate investigation and intervention of sentinel events, including both those reviewable by The Joint Commission and those that are not reviewable by the Joint Commission.
Gathers, monitors, and maintains awareness of current clinical outcomes data; timely informs and presents data to leaders of trends. Leads and/or participates in efforts to improve outcomes.
Conducts routine audits and mock surveys to aid in preparedness, tracking, trending, and facilitation of corrective action plans.
Evaluates regulatory compliance concerns and makes recommendations for improvement to ensure that safety/regulatory recommendations are implemented in accordance with accreditation standards and guidelines.
Mitigation of Risks:

Develops formal and informal mechanisms for risk identification and undesirable outcomes in care, including but not limited to, Incident Reports, Safety, Security and Facility Reports, patient complaints, review of pertinent quality improvement information, internal and external audits, staff referrals, and medical records reviews/ chart audits.
Develop statistical and qualitative reports on risk management issues, tracking and trending patterns, communicating this information effectively to administration, leadership and other appropriate audiences.
Develop policies and procedures in key areas designed to mitigate clinical risk and/ or improve patient outcomes; acts as a resource to other departments developing policies, procedures, and improved processes intended to mitigate patient risk of harm.
Promotes a positive work culture and upholds Pipeline Health policies and procedures, including the Pipeline Health Code of Conduct.
Standard:

Uses AIDET in interactions with patients and family members.
Acts with a sense of urgency when performing tasks.
Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
Reports on any equipment and or environmental issues for repair.
Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
Speaks up to stop the line and escalates potential safety events if necessary.
Completes and attends monthly training assigned.
Other duties as assigned.
Must always uphold confidentiality in regard to Pipeline Health activities, reports, financials, patient health information and other proprietary information specific to Pipeline Health.
Behavioral Standards:

Strong understanding of risk management, patient safety, and regulatory principles and practices.
Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
Ability to think strategically and creatively, juggle multiple priorities, adjust to changing circumstances, organize time efficiently and remain attentive to details.
Ability to work with highly confidential information daily.
Uses a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.
Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints and questions; displays a positive attitude.
Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.
Communication/Knowledge:

Maintains open lines of communication with all hospital departments.
Knowledge of organization performance improvement techniques and tools.
Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the Pipeline Health facilities.
Demonstrates knowledge of current performance improvement methodology and practices.
Maintains current knowledge of accreditation and licensing requirements and must be a resource to