Sentinel Event Program Manager (HQ)

Description

The Sentinel Event Program Manager reports to the Health Service Division’s Director of Quality.

The Sentinel Event Program Manager responsibilities:

• Responsible for the management, operation, and coordination of assignment deliverables of the Department's Care Review Appeals, Mortality Review and Unexpected Fatality Review Committees.
• Designated as the Department's lead for managing how these committees operate, ensuring that all case presentations have been sufficiently/accurately researched and that relevant subject matter experts from Department of Corrections (DOC), Department of Health (DOH), Office of the Corrections Ombuds (OCO) and Health Care Authority (HCA) are represented when needed at any one of these committee meetings.
• Supervises a Sentinel Event Review Specialist and works directly with members assigned to these committees to review the circumstances and records of each individual's fatality or care review appeal. Committee members are responsible to explore the root causes that contributed to findings and to propose recommendations for corrective action to prevent future fatalities and strengthen the safety and health protections of persons in the custody of the department.
• Ensures that committee and corrective action reports are completed, reviewed, approved, and issued to the Governor's office, legislature and posted to the Department's public facing website within required timelines.

Duties

• Designated as Department lead responsible for operation, management, and facilitation of the Department’s Mortality Review Committee.
• Ensures that Department’s Mortality Review Committee (MRC) completes a multidisciplinary mortality case review for every incarcerated individual whose fatality occurred while in Department custody within 60 days from the date of fatality.
• Schedules, organizes, and convenes a weekly mortality review committee attended by medical, behavioral/mental health, nursing, pharmacy, dental and reentry providers to conduct a post-mortem review of an incarcerated individual’s medical care to explore root causes and identify interventions to prevent future fatalities.
• When it is unclear what may have caused a finding, ensures that a root cause analysis is assigned and completed within 60 days of the date of fatality to inform what corrective actions should be taken to mitigate the risk that a finding will occur again.
• Compiles, reviews, and prepares medical records received and assigns medical professionals who are responsible to review these records and present the case to members of the mortality review committee.
• Contacts county medical examiners, hospitals, and community jails to obtain copies of medical records (i.e., assessments, autopsy results, death certificate, toxicology reports, etc.) for use in conducting the Department’s mortality reviews.
• Ensures that all MRC members have a signed confidentiality statement on record and that these are updated at least annually.
• Reviews and tracks the status of previously assigned action items to ensure completion.
• Ensures that Mortality Review Committee Teams’ and SharePoint sites contain all records and notes used in the Committee’s review and that records are secure and available should Department be required to give an account regarding findings and the completion status of MRC adopted action items to correct findings.
• Reviews and updates MRC charter at least annually to ensure that information contained within is current.
• Refers cases reviewed by MRC to Unexpected Fatality Review (UFR) committee within 60 days from the date of fatality when MRC committee determines that the fatality meets criteria as an
• “Unexpected” fatality per RCW 72.09.770.
• Trains and orients MRC members regarding committee processes, responsibilities, and expectations.

• Ensures that the UFR Committee conducts an unexpected fatality review in any case in which the fatality of an incarcerated individual is unexpected, or in any case identified by the Office of the Corrections Ombuds for review.
• Designated as the Department’s lead responsible for the operation, management, and facilitation of the Department’s Unexpected Fatality Review Committee.
• Prior to UFR Committee meeting, this position is responsible to review the MRC report, Critical Incident or Administrative Review Report, and capture any recommendation directly related to the fatality.
• Develops case presentation for each fatality that UFR Committee Members are to review. UFR case presentations typically include the following information: Incarceration history summary, personal goals, personal interests, relationships/family, timeline of events leading up to the individual’s fatality, summary of critical incident reports findings and recommendations, summary of medical record review, summary of findings and recommendations from the completed mortality review.
• Ensures that UFR case presentations are posted to the secure UFR Committee Team site at least 2 weeks prior to the UFR Committee meeting. This allows committee members time to review and prepare questions and recommendations prior to the meeting. If records are not available, communicates with committee
• members to provide information about why there is a delay.
• Responsible for documenting questions, information shared, and recommendations proposed by UFR Committee members and ensures that this information is included in the UFR Committee’s final report.
• Responsible to DRAFT UFR Committee and Corrective Action Reports and to send to UFR Committee members for review and approval before sending to DOC Secretary and Deputy Secretary for final review and approval before sending to the Governor, WA State Legislature, and posting on DOC’s public facing website.
• Ensures that UFR Committee reports are published within 120 days from the date of the unexpected fatality.
• Ensures that UFR Committee Corrective Action Plan (CAP) reports are published within 130 days from the date of the fatality.
• Ensures that Items identified for corrective action in the UFR Committee CAP report are completed within 120 days from the date that the CAP report is published.
• Ensures that CAP Tracking Database on UFR Team site is current and up to date with information regarding the completion status of CAP items.
• When there are delays in obtaining medical records, death certificates and autopsy results, initiates formal extension request to HS Assistant Secretary.
• Produces and presents UFR Outcomes report to Health Services Administrative Services Board annually.
• Functions as UFR Committee’s liaison to other State Agencies and Department Divisions.
• Train and orient UFR committee members regarding committee processes, responsibilities, and expectations.

• Designated as Department lead responsible for operation, management, and facilitation of the Department’s Care Review Appeal Committee.
• Ensures that Department’s Care Review Appeal Committee completes a review for every incarcerated individual who appeals a care review committee (CRC) decision within 30 days from the date of the appeal.
• Schedules, organizes, and convenes a monthly appeal committee attended by physicians and/or dentists who were not involved in the previous CRC decision.
• Compiles, reviews, and prepares medical records received, produces a care summary, and assigns medical professionals who are responsible to review these records and prior to making a decision regarding the appeal request.
• Ensures that Care Review Appeal Committee’s Teams and SharePoint sites contain all records and notes used in the Committee’s review and that records are secure and available should Department be required to give an account regarding findings and the completion status.
• Produces and distributes notification of Committee decisions to the patient, HSM and primary care provider.
• Produces and presents Care Review Appeals Outcomes report to Health Services Administrative Services Board annually.

• Provides support to DOC’s clinical leads in their review of medical records to prepare for public disclosure requests, depositions, and legislative testimony related to fatalities and care review appeals.
• Conducts legislative bill analyses within 48 hours of assignment, during legislative session, to determine impacts to the Department if bill were to be adopted by the legislature.
• Demonstrate professionalism and DOC values in all aspects of work.
• Provides support to other HS and/or DOC efforts as directed.
• Assists with Adverse Event external reporting and Root Cause Analysis (RCA) projects as assigned.

Qualifications

Required Qualifications:

AND

• A minimum of three (3) years of professional experience with working with appointed and elected government executives, legislative bodies and community stakeholder groups.
• Knowledge of and ability to apply principles, practices and methods of systems thinking and change Knowledge of and ability to apply quantitative and qualitative research methods
• Knowledge of and ability to apply Lean principles, practices and methods.
• Knowledge of and ability to apply change management principles, practices and methods
• Knowledge of and ability to apply advanced facilitation techniques Ability to recognize, detect, and resolve complex operational issues.
• Ability to create and maintain good working relationships through excellent communication and team building skills, including the ability to engage successfully with both internal and external stakeholders.
• Exceptional communication skills, both verbal and written, including the ability to prepare and deliver clear and concise presentations, reports and data visuals/dashboards.
• A professional level of expertise in multiple areas of large-scale and complex operations and demonstrated use of high-level discretion and judgement in execution of duties.
• Ability to maintain strict confidentiality and handle difficult situations with diplomacy, tact and empathy. Ability to manage and maintain simultaneous, transitional, and emerging priorities.
• Ability to advance DOC values, including Equity, Diversity, Inclusion and Respect.

Preferred Qualifications

Supplemental Information

• Mission: The mission of DOC is to improve public safety by positively changing lives.
• Our Vision: Working together for safer communities.
• Our Commitment: To operate a safe and humane corrections system and partner with others to transform lives for a better Washington.
• Our Core Values:
  • Cultivate an environment of integrity and trust: Corrections values partnership and trust. We foster openness and support courageous conversations. We are committed to doing what we say we are going to do by being accountable and taking personal ownership in our actions.
  • Respectful and inclusive interactions: Corrections appreciates and values individuals by promoting an inclusive and diverse environment, which encourages safety. We respect, value, and listen to the thoughts, feelings, and perspectives of our stakeholders and consider the impact on those we serve as well as each other.
  • People's safety: Corrections believes in creating an environment that values physical, mental, and emotional security and well-being. We honor those who advance safety for all.
  • Positivity in words and actions: At Corrections, we assume positive intentions and believe there is a shared desire for the best outcome. We consistently demonstrate positive behavior and always put forth our best effort.
  • Supporting people's success: Corrections is committed to our community – understanding individuals, instilling hope, embracing change, and providing opportunities.

Important Notes or Additional Information

• Please include a minimum of three (3) professional references with your application. A professional reference is defined as an individual who has been paid to supervise your work and can attest to your work performance, technical skills, and job competencies. If you do not have any or sufficient professional references, please include non-related professionals, such as educators or other professional associates.

• A background check including criminal record history will be conducted prior to a new hire. Information from the background check will not necessarily preclude employment but will be considered in determining the applicant’s suitability and competence to perform in the position.
• Employees may work directly with or near incarcerated individuals in a potentially hazardous setting. Please consider this when deciding whether to apply.
• We are committed to maintaining a drug and alcohol-free work environment, and our employees are expected to comply with all state and federal laws. A pre-employment drug test may be administered as part of the selection process, and applicants who test positive for any controlled substances, will be disqualified from consideration.
• Oleoresin Capsicum (OC) is an aerosol pepper spray made available as a means of self-defense and/or de-escalation. Applicants with sensitivities or allergies are encouraged to ask about the level of exposure they could expect in this position.
• Animal care projects are a common component of most Washington State prisons, including dog and cat programs. Applicants with animal sensitivities or allergies are encouraged to ask about the level of exposure they could expect in this position.
• Tuberculosis (TB) is a priority health issue for DOC employees. The successful candidate may be required to provide valid proof of a baseline TB skin test within 60 days from the date of hire. When positive tests result, further information, testing and treatment will also be required. Employment is not contingent upon test results.
• This position may be represented by a bargaining unit.

• Requires respirator medical evaluation questionnaire, fit testing, training, and use of respiratory protection as required by the WA Industrial Safety & Act standards. Refer to WAC 296-842 to learn more.
• Must be able to work in spaces, climb stairs, walk long distances, and frequently lift up to 30 pounds. Under rare circumstances this position may be required to lift or carry up to 50 pounds and push up to 100 pounds.
• Foreign equivalent degrees awarded outside the United States must have a credential evaluation report attached to your application. You may request the required evaluation/documentation from www.wes.org and www.aice-eval.org. Until this documentation is provided, you will not be selected to move forward in the hiring process.
• Candidates who are offered a job with the Department of Corrections must possess work authorization that does not require sponsorship by the employer for a visa now or in the future.
• (FOR RN POSITIONS) Salary is based on experience and is determined at the time a final offer of employment is made. The salary range listed in the job posting includes Steps A-U. Step U is a longevity step and is typically gained six years after being assigned to Step T in your permanent salary range.
• (FOR ALL OTHER NON WMS POSITIONS) Salary is based on experience and is determined at the time a final offer of employment is made. The salary range listed in the job posting includes Steps A-M. Step M is a longevity step and is typically gained six years after being assigned to Step L in your permanent salary range.
• DOC complies with the employment eligibility verification requirements for the federal employment eligibility verification form I-9. The selected candidate must be able to provide proof of identity and eligibility to work in the United States consistent with the requirements of that form. https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents
• DOC does not use E-Verify; therefore, we are not eligible to extend STEM-Optional Practice Training (OPT). For information, please visit www.uscis.gov.

• Work effectively with people of different perspectives, abilities, disabilities, races, religions, ages, lifestyle preferences and social, ethnic and cultural backgrounds.
• Respectfully acknowledge people's differences and recognize these differences as important and valuable.
• Promote inclusiveness.
• Be culturally sensitive and appropriate.
• Respect and value diverse backgrounds and traditions.

• Up to 25 paid vacations days a year
• 8 hours of paid sick leave per month
• 12 paid holidays a year
• Generous retirement plan
• Flex Spending Accounts
• Dependent Care Assistance
• Deferred Compensation and so much more!

DOC is an equal opportunity employer and does not discriminate on the basis of race, creed, color, national origin, sex, marital status, sexual orientation, gender identity, gender expression, age, honorably discharged veteran, veteran status, genetic information, or the presence of any sensory, mental or physical disability or the use of a trained guide dog or service animal by a person with a disability.

For questions about this recruitment, or to request reasonable accommodation in the application process, please emailkathey.waggoner@doc1.wa.gov or call at (509) 907-7808.

For TTY service, please call the Washington Relay Service at 7-1-1 or 1-800-833-6388.