Position Summary:
The Risk Management & Patient Safety Coordinator is responsible for coordinating, implementing, and evaluating Sage Memorial Hospital's Risk Management and Patient Safety programs. The incumbent works collaboratively with clinical staff, providers, leadership, and regulatory agencies to identify, assess, and mitigate risks that may affect patient care, employee safety, organizational operations, and regulatory compliance.
A clinical background and Registered Nurse (RN) license are strongly preferred; however equivalent experience in healthcare quality, patient safety, risk management, public health, healthcare administration, or related healthcare fields will be considered.
The Coordinator facilitates incident investigations, adverse event reviews, root cause analyses (RCA), failure mode and effects analyses (FMEA), and risk assessments to improve outcomes and prevent the recurrence of events. The position promotes a culture of safety, Just Culture principles, and continuous quality improvement through education, data analysis, regulatory readiness, and performance improvement activities.
The Coordinator serves as a resource for patient safety, risk reduction, accreditation compliance, regulatory requirements, and evidence-based practices while supporting the organization's mission to provide safe, high-quality healthcare services.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Essential Duties & Responsibilities:
Confidentiality & Professional Practice
- Maintain strict confidentiality of patient, employee, and organizational information in accordance with HIPAA, hospital policies, and applicable regulations.
- Demonstrate professional healthcare practice standards and ethical conduct in all aspects of risk management and patient safety activities.
- Promote a culture of accountability, transparency, and continuous improvement throughout the organization.
Risk Management
- Coordinate the organization's Risk Management Program and related activities.
- Investigate adverse events, patient complaints, grievances, near misses, and other incidents with potential clinical, regulatory, or legal implications.
- Conduct clinical and operational reviews and analyze event reports to identify actual or potential risks to patients, staff, visitors, and the organization.
- Facilitate Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and other risk assessment methodologies.
- Develop, implement, and monitor corrective action plans designed to reduce risk and improve patient outcomes.
- Collaborate with clinical leadership, medical staff, and department managers to identify risk reduction strategies and monitor effectiveness.
- Assist with the investigation and documentation of potential claims, liability events, and regulatory concerns.
Patient Safety
- Coordinate and support the hospital's Patient Safety Program and related initiatives.
- Promote a Just Culture environment that encourages reporting of safety concerns, close calls, and adverse events without fear of retaliation.
- Monitor, track, trend, and analyze patient safety indicators, including falls, medication errors, pressure injuries, hospital-acquired conditions, and other adverse events.
- Conduct patient safety rounds and collaborate with leadership to address identified concerns.
- Coordinate investigations and follow-up activities related to sentinel events and serious safety events.
- Support implementation of evidence-based patient safety practices and organizational safety goals.
Quality & Performance Improvement
- Participate in hospital-wide quality improvement and performance improvement initiatives.
- Collect, analyze, and report risk management and patient safety data to identify trends and opportunities for improvement.
- Prepare reports, dashboards, and presentations for leadership, committees, and the Board of Directors regarding risk and patient safety performance.
- Support the administration and analysis of patient safety culture surveys and assist with action plan development.
Regulatory Compliance & Accreditation
- Assist departments in maintaining compliance with Joint Commission, CMS, OSHA, HIPAA, FTCA (Federal Tort Claims Act), tribal healthcare requirements, and other applicable regulations.
- Participate in accreditation readiness activities, regulatory surveys, and corrective action monitoring.
- Review and assist in developing policies, procedures, and educational materials related to risk management and patient safety.
- Maintain current knowledge of applicable healthcare laws, regulations, accreditation standards, and best practices.
Education & Collaboration
- Provide education and training to staff on patient safety principles, risk reduction strategies, event reporting, Just Culture, and regulatory requirements.
- Serve as a resource to leadership, clinical staff, providers, and departments regarding patient safety and risk management concerns.
- Participate in interdisciplinary committees and workgroups related to quality, safety, compliance, and risk management.
Other Duties
- Support the mission, vision, values, and strategic goals of Sage Memorial Hospital.
- Perform other duties as assigned to support organizational quality, patient safety, compliance, and risk management objectives.
Minimum Qualifications:
- Must be able to successfully pass all Employee Health Program requirements and background investigation in accordance with hospital policy and applicable regulations.
- Current, unrestricted Registered Nurse (RN) license strongly preferred but not required.
- Bachelor’s degree in Nursing, Public Health, Healthcare Administration, Risk Management, Quality Management, Health Science, or related healthcare field required.
- Master’s degree in Nursing, Healthcare Administration, Public Health, Quality, Risk Management, or related field preferred.
- Minimum of three (3) years of experience in healthcare quality, patient safety, risk management, accreditation, regulatory compliance, performance improvement, clinical operations, case management, or a related healthcare field required.
- Clinical experience as a Registered Nurse or other licensed healthcare professional is strongly preferred.
- Experience in Risk Management, Patient Safety, Quality Improvement, Accreditation, Regulatory Compliance, Case Management, or Performance Improvement preferred.
- Experience conducting incident investigations, root cause analyses (RCA), and/or failure mode and effects analyses (FMEA) preferred.
- Working knowledge of Joint Commission standards, CMS Conditions of Participation, OSHA regulations, HIPAA requirements, FTCA requirements and applicable tribal healthcare regulations preferred.
- Ability to obtain Certified Professional in Healthcare Risk Management (CPHRM) certification within two (2) years of hire preferred.
- Certified Professional in Patient Safety (CPPS) and/or Certified Professional in Healthcare Quality (CPHQ) preferred.
- Demonstrated ability to analyze data, identify trends, develop corrective action plans, and effectively communicate findings to clinical and leadership teams.
- Strong organizational, problem-solving, communication, and interpersonal skills required.
- Candidates with demonstrated experience in healthcare quality, patient safety, risk management, compliance, accreditation, or healthcare operations will be considered regardless of professional licensure.
Knowledge, Abilities, Skills, and Certifications:
Knowledge
- Knowledge of healthcare risk management principles, patient safety practices, quality improvement methodologies, and performance improvement processes.
- Knowledge of federal, state, tribal, and local healthcare regulations, including CMS Conditions of Participation, Joint Commission standards, OSHA, HIPAA, FTCA requirements and applicable patient safety requirements.
- Knowledge of clinical workflows, healthcare delivery systems, and healthcare practice standards.
- Knowledge of incident reporting systems, event investigation methodologies, Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and Just Culture principles.
- Knowledge of patient safety indicators, regulatory reporting requirements, accreditation standards, and risk reduction strategies.
- Knowledge of medical liability, claims management, informed consent, documentation standards, and healthcare legal concepts related to risk management.
- Knowledge of data collection, analysis, trending, and reporting techniques used to support quality, safety, and risk management activities.
Abilities
- Ability to communicate effectively, both verbally and in writing, with patients, staff, providers, leadership, attorneys, and regulatory agencies.
- Ability to conduct objective investigations and maintain confidentiality regarding sensitive information.
- Ability to analyze complex clinical, operational, and regulatory issues and develop appropriate recommendations.
- Ability to interpret and apply healthcare laws, regulations, accreditation standards, and organizational policies.
- Ability to facilitate multidisciplinary teams in solving problems and implementing corrective actions.
- Ability to prioritize multiple projects, meet deadlines, and work independently with minimal supervision.
- Ability to educate and coach staff regarding patient safety, risk reduction, and regulatory compliance.
- Ability to establish and maintain effective working relationships with individuals from diverse professional, cultural, and social backgrounds.
Skills
- Strong analytical, critical thinking, investigation, and problem-solving skills. Clinical assessment experience is strongly preferred.
- Skilled in incident investigation, root cause analysis, risk assessment, and corrective action planning.
- Skilled in collecting, analyzing, interpreting, and presenting risk management and patient safety data.
- Skilled in developing policies, procedures, educational materials, and performance improvement initiatives.
- Skilled in conflict resolution, collaboration, and facilitation of interdisciplinary teams.
- Proficient in Microsoft Office applications including Outlook, Word, Excel, PowerPoint, and electronic reporting systems.
- Skilled in preparing reports, presentations, and regulatory documentation.
Certifications & Licensure
- Current unrestricted Registered Nurse (RN) license strongly preferred but not required.
- Other clinical licensure (e.g., NP, PA, Pharmacist, Respiratory Therapist, or other licensed healthcare professionals) may be considered.
- Basic Life Support (BLS) certification preferred.
- Certified Professional in Healthcare Risk Management (CPHRM) preferred or obtained within two (2) years of hire.
- Certified Professional in Patient Safety (CPPS) preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Additional education or certification in healthcare compliance, accreditation, patient safety, risk management, or quality improvement is preferred.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.
- Regularly required to sit, speak, hear, and use hands and arms to reach, handle, grasp, and manipulate objects, documents, computers, and office equipment.
- Frequently required to walk throughout hospital and clinic facilities to conduct patient safety rounds, incident investigations, attend meetings, and collaborate with staff.
- Occasionally required to stand, stoop, kneel, crouch, bend, or crawl while conducting inspections, reviewing environmental safety concerns, or accessing records and equipment.
- Must occasionally lift, carry, push, and/or move up to 25 pounds, including files, training materials, office equipment, and supplies.
- Requires visual acuity sufficient to review medical records, analyze data, prepare reports, and operate computer equipment.
- Requires manual dexterity sufficient to operate computers, telephones, and other office equipment.
- Must be able to communicate effectively in person, virtually, and by telephone with staff, providers, patients, regulatory agencies, and external partners.
- Must be able to work in both office and clinical environments and may require travel throughout the organization to perform investigations, audits, rounding activities, and committee participation.
- Must be able to maintain physical and mental stamina necessary to manage multiple priorities, respond to urgent patient safety or risk events, and meet reporting deadlines.
Work Environment:
Work is primarily performed in an office setting with a moderate noise level typical of healthcare administrative and clinical support areas. The position requires frequent interaction with providers, clinical staff, department leaders, patients, regulatory agencies, and other healthcare professionals. The incumbent regularly travels throughout hospital and clinic facilities to conduct patient safety rounds, incident investigations, observations, audits, and committee activities.
The normal work schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. Additional hours may occasionally be required to support incident investigations, accreditation surveys, regulatory reviews, urgent patient safety events, or organizational needs.
Limited remote work may be approved at the discretion of leadership when operationally appropriate; however, regular on-site presence is required to effectively perform investigations, collaborate with clinical teams, participate in meetings, conduct rounding activities, and support patient safety and risk management functions.
The position may occasionally be exposed to patient care environments and must comply with all infection prevention, safety, and personal protective equipment (PPE) requirements.
