Risk Management/Privacy & Patient Safety Officer

SUMMARY:

Responsible for enterprise-wide risk management and patient safety plan. Responsible to eliminate or reduce the incidence and severity of harm/loss to patients, families, staff, and the organization. Assists in the identification, management and reduction of risk involving both clinical scenarios, general and specific liability exposures. Serves as the Health System Privacy Officer and Patient Safety Officer and oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the healthcare organization’s information privacy practices. Assists, as directed, with clinical compliance investigations and audits.

ESSENTIAL DUTIES AND RESPONSIBILITIES: include the following:

Serves as the Risk Management, Patient Safety, and Privacy subject matter expert and provides consultation and education to clinical practitioners, administration, and staff; functions as process improvement team leader/member to reduce hospital-acquired conditions, injuries, errors, and unintended outcomes. This expertise is provided in various venues as appropriate or assigned.

Develops, monitors, and reports activities to improve patient safety (focusing on National Quality Forum (NQF) Safe Practices, Hospital Acquired Conditions (HACs), and Institute for Healthcare Improvement (IHI) and Agency for Healthcare Research and Quality (AHRQ) indicators). Responsible for patient safety standards in the applicable accreditation survey, state licensure regulations and federal conditions of participation.

Identifies and implements patient safety best practice initiatives by reviewing sentinel event alerts, Patient Safety Organization information, and other key organizations and references. Participates in event analysis and case reviews.

Interacts with clinical staff regarding ongoing investigations and corrective action plans.

Reviews care and treatment provided by staff and providers as part of the peer review or other event analysis processes.

Prepares and submits summary reports to the Environment of Care, Compliance Committee, Medical Staff Quality Committee, Board Quality Committee, and Board of Directors as assigned. Creates reports and develops graphical displays for presentations.

Recommends appropriate revisions to new or existing policies related to areas of expertise.

As assigned, works under the direction of the Director of Quality & Regulations to investigate events, conduct research, or other relevant activities associated with the department.

Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the organization’s privacy policies and procedures.

Oversees, directs, delivers, or ensures delivery of initial and privacy training and orientation to all employees, volunteers, medical and professional staff. Promotes activities to foster information privacy awareness within the organization and related entities.

Performs initial, and periodic information privacy, and clinical compliance risk assessments and audits.

Provides development guidance and assists in the implementation and maintenance of organization information privacy policies and procedures.

Works cooperatively with the Health Information Management (HIM) Director, and other applicable organization units, in overseeing patient rights to inspect, amend, and restrict access to protected health information when appropriate.

Works with legal counsel and management, key departments, and committees to ensure the organization has and maintains appropriate privacy and confidentiality consent, authorization forms, and information notices and materials reflecting current organization and legal practices and requirements.

Analyzes event-reporting data, identifies trends, and develops plans for improvement with key stakeholders.

Conducts or facilitates Failure Mode and Effects Analysis (FMEA) when indicated on prospective operations and performs or facilitates Event Analysis/Root Cause Analysis (RCA) according to policy. Reports event summaries and action plans to appropriate venues; monitor corrective actions implemented from same.

In conjunction with TFH Legal Department, and outside counsel, participates in all litigation related to health care liability, personal injury, premises/property, crime, Director and Officers, Errors and Omissions, cyber liability and other claims matter within the areas of responsibility. Monitors legal performance and costs in areas of responsibility, and serves as liaison to insurers and retained legal counsel. Attends any legal proceeding as District (corporate) representative, as appropriate.

Maintains knowledge of state and federal regulations, proposed changes or revised interpretations, related to healthcare law.

Responsible for all-lines of insurance programs for the District (except the employee health benefits and Workers’ Compensation); to include claims management with insurers, renewal applications, certificates of coverage, risk analysis and coverage determinations. Responsible to preserve District’s insurance coverage through timely and proper notice of claims to any insurer for any covered event.

Demonstrate System Values in performance and behavior.

Comply with System policies and procedures.

Other duties as may be assigned.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SUPERVISORY RESPONSIBILITIES:

No supervisory responsibility.

EDUCATION AND EXPERIENCE:

A minimum of four years of related experience in risk management, patient relations, privacy, patient safety, and/or quality management in a hospital or health care setting is required. Recent experience in a related position with a history of receiving direction from a risk/quality/patient safety manager. Three to five years of experience in managing insurance programs in complex medical organizations.

LICENSES, CERTIFICATIONS:

Current California RN License or commensurate clinical license and/or healthcare degree and Certified Professional in Healthcare Risk Management; Certified investigator/examiner. Certification may be obtained within the first two (2) years of employment.