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Quality Safety & Risk Specialist (RN)

General Summary
The Quality Safety and Risk Leader for St. Joseph Mercy Chelsea is responsible for the facility's risk management activities in both in patient and outpatient settings, which may include, but may not be limited to, coordinating insurance coverage and risk financing, managing claims against the facility, interfacing with defense legal counsel, administering the risk management program on a day-to-day basis, managing and analyzing risk management data conducting risk management educational programs, complying with risk management related standards by The Joint Commission (TJC), all with the objective of maintaining patient safety, enhancing quality care, and minimizing loss to protect the assets of the facility. This individual provides leadership and expertise in the areas of external regulatory, compliance, quality and patient safety standards as it relates to associates, staff and units of Saint Joseph Mercy Health System. This individual functions as the Patient Safety Officer / Lead for St. Joseph Mercy Chelsea and all associated outpatient sites. This position functions at the Trinity Heath Risk Manager Level 2 job description role. See Addendum.
Job Duties
Functions as the Patient Safety Officer and coordinates investigation of potential or actual problems.
Manages and directs the implementation of organizational quality and safety activities across all areas in SJMHS, partnering with unit and program managers and leaders as appropriate.
Leads and organizes the St. Joseph Mercy Chelsea Quality and Patient Safety Committee.
Coordinates the initial investigation of potential or actual adverse events, facilitates Root Cause Analysis of events. Collaborates with the appropriate leadership to establish implementation timelines and monitors the closure of the corrective action plan.
Develops, implements, and oversees the Serious Reportable Event function and process.
Develops and provides ongoing reports to senior leadership and the Quality Committee of the Board. Presents and/or reports risk, quality, and safety issues, outcomes and recommendations.
Collaborates with quality representatives in developing Performance Improvement Plans, indicators and goals. Facilitates proactive risk assessment and reduction via tools such as Failure Modes and Effects Analysis. Plans, develops and presents facility wide educational programs for Medical Staff, Clinical and Non-clinical associates, residents and students pertaining to patient safety, performance improvement and risk management.
Supports the implementation of Trinity Health goals established in collaboration with IRMS and the Risk Management Council.
Assists with all risk management support activities, including the following: the claims/litigation process, acquiring exposure data to facilitate insurance procurement,
Provides consultation services to all medical staff departments in relation to patient safety, risk management and compliance with legal and/or regulatory requirements. Works with Department Chair, Chief of Staff and legal council on medical staff member peer review and/or other investigations, maintaining confidential files. Maintains awareness of legislative and regulatory activities related to health care risk management. Maintains working knowledge of TJC and CMS regulations. Complies with various codes, laws, rules and regulations concerning patient care, including those mandated by state and federal agencies, incident reporting, also includes investigative activities with federal, state and local enforcement authorities.
Other Duties
Serves as local patient advocate for patients/families. Facilitates investigation into significant complaints, working with applicable staff for resolution. Has authority to initiate medical write-offs. Reviews daily all incident reports submitted and works with applicable managers as needed for review/investigation of reports. Serve on Ethics Committee, assisting with Ethics consults and education.
Degree(s), License(s) and/or Certification(s) Required
Bachelor's degree in Nursing or other related field required. Masters preferred.
Certified Professional in Healthcare Risk Management - CPHRM Certification or must attain within 2 years of employment.
4-8 years of progressive health care management experience in medical staff issues, clinical practice areas, quality/risk management or performance improvement.
Working knowledge of laws, regulations, accrediting, licensing, monitoring agency standards and requirements applicable to medical staff, risk management and safety.
Experience and Skills Required
Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization, especially department management, medical staff and administrative leadership.
Strong organizational and time management skills; able to research, plan, develop, implement and maintain projects to meet established goals/deadlines.
High level of problem solving skills necessary to determine needs and to help facilitate changes, maintaining end-user satisfaction.
Self directed, proactive and solution oriented in approach to work and serve the needs of the end-users.
Ability to facilitate or provide educational programs for all staff related to risk education, reduction, regulatory/legal changes, etc.
Possesses strong verbal and written communication skills with all of SJMHS departments and staff. Ability to work with others to solve complex problems, resolve patient concerns and/or develop approaches that support delivery of quality, safe care to patients while recognizing individual patient rights.
Reporting relationship
Reports to the SJMHS Director of Clinical Quality Safety and Risk Services. Matrix reporting relationship to the SJMHS Director of Performance Improvement.
This document is intended to describe the generalized duties and responsibilities, the specialized job functions, and the essential requirements of this job. It is not intended to be an exhaustive statement of all supplemental duties, responsibilities, or non-essential requirements or reflect any accommodations made under the American's with Disability Act, the Michigan Handicapper's Act, or SJMHS' Return to Work Program


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