Risk, Safety, and Regulatory Specialist

*All duties listed below are essential unless noted otherwise*

1. Develop and implement a proactive, comprehensive clinical risk management and patient safety program. This includes incident investigations, risk audits, standardization of policies, and support to patient safety initiatives that will ultimately result in a reduction of patient injuries,
2. Coordinate with other system clinical risk and patient safety specialists on implementation of risk management and patient safety programs and policies. Implement and monitor policies and procedures for best practices in healthcare clinical risk management and patient safety. Assist with integration of new facilities into risk management and patient safety program.
3. Develop and encourage a reporting culture throughout the organization. Review Safety Event and Risk Management Reporting incident reports and supervisor follow-ups. Compile, analyze, and interpret statistical data related to errors and near misses. Prepare reports and offer recommendations for resolution to administration. Educate and assist departments in recognizing the causes of incidents and methods to prevent or reduce the number and severity of such incidents.
4. Lead teams in the analysis and scoring of safety events and implement action plans that support error prevention and a cultural shift to high reliability.
5. Maintain and Report the Patient Serious Safety Event Rate for the business units and system, interpreting the data to facilitate changes in the safety culture. Report results and implement necessary changes based on the organization's annual Safety Culture Survey across all business units and service lines.
6. Lead teams to conduct Root Cause Analyses of system-level and business unit events. Collect data from Root Cause Analyses to support Common Cause Analysis and corrective action initiatives.

7. Conduct routine, periodic risk inspections and audits. Develop loss control reports to department heads and administrators for correction. Follow-up on corrective measures.

8. Provide advisory support to clinical staff and leadership on matters of clinical risk and patient safety.
9. Explore industry methods for continuous improvement in patient safety and clinical risk management through data and research from safety and risk organizations, journals, and conferences. Determines feasibility of bringing new initiatives into the system.
10. Maintains current knowledge of regulatory standards and survey processes for all regulatory bodies who oversee deemed status and specialty designations (e.g., CMS, TJC, ACHC, OSHA, ODH, MDHHS, etc.).
11. Informs senior leadership of current and potential regulatory/continual readiness issues at site- and system-levels. Serves as a resource and mentor to senior leadership on regulatory topic interpretations.
12. Initiates, conducts, analyses, and reports on process improvement efforts by utilizing tools including, but not limited to audits, rounds, PDSAs, gap analyses, FMEAs, and tracers to guide organization in assuring system-level continual readiness.
13. Guides all levels within the organization in preparation for surveys, site visits, and regulatory reviews; manages survey processes to assure compliance during review with organizational policy and associated regulations; guides creation of and monitors ongoing adherence with process improvement secondary to survey findings.
14. Assists in the creation of education for all levels of leadership as required to maintain a culture of continual readiness.
15. Collaborates with and guides Chapter Chairs, senior and frontline leadership to identify patient safety and regulatory concerns, and initiates action plans with a system-level approach whenever appropriate to opportunities identified.
16. Attends and/or manages meetings to disseminate regulatory information and findings on a routine and as-needed basis across the organization.
17. Investigates payer and regulatory quality of care concerns and guides action plan creation and written responses in collaboration with affected leadership.
18. Assists in the creation and maintenance of regulatorily required documents, including but not limited to policies; guidelines; scopes of service; statement of deficiency forms; other written regulatory responses; required survey documents; deemed status application updates; hospital licensure letters; etc.
19. Supports organizational initiatives round clinical specialty certification and serves as a consultant for excellence in patient care.
20. Other duties as assigned

Education: Bachelor's degree in nursing or related field.
Skills: Word, Excel, PowerPoint, RL6
Years of Experience: 5 years
License: RN
Certification: N/A

Education: Master's degree in related field.
Certification: CPHRM, CPPS, HACP - Center for Medicare & Medicaid Services (CMS)
Years of Experience: 5 years
License: N/A