Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible.
Under the minimal supervision of the Director of Patient Safety & Risk Management, the Clinical Risk Manager, provides consultation and expertise for regulatory requirements promulgated by the New York State Department of Health and CMS and Joint Commission. Uses professional judgment and advanced knowledge in risk management issues to serve as a support for the organization.
The Risk Manager is responsible for the administration of the institutional systems to comply with regulatory reporting initiatives including the New York State Patient Occurrence Tracking and Reporting System (NYPORTS). Responsible for the information gathering, data analysis, investigation, and response to Sentinel Events, and NYPORTS events and applies the appropriate and current root cause analysis methodology to the investigative process. Investigates all near-miss events. Independently performs follow-up as needed to assure recommended reviews and investigation inquiries regarding quality-of-care issues. Tracks and trends NYPORTS quality outcomes and makes recommendations as needed.
Responsible for the coordination of clinical reviews as needed. Works closely with departments to recommend and implement system improvements as a result of the RCA and investigative process actions. Responsible for monitoring the sustainability of actions. Assists the Director with maintaining a Culture of Safety. Serves as a knowledgeable resource for risk issues, and legal and regulatory matters. Reviews, investigates, and analyzes Medication Variance Reports for trends, safety, and liability issues for the organization.
Prepares quarterly and annual reports for various committees including the Board of Trustees Performance Improvement Committee, Board of Trustees, and Annual Safety Report with analysis of trends.
Acts as a consultant to providers and staff members on all risk management issues. Represents Risk Management on a number of different teams including Medication Safety, Emergency Preparedness, Morbidity & Mortality, and Risk Reduction Committees (falls, medication errors, pressure ulcers, DVT, etc) as well as other committees as assigned. Participates in special studies and other duties as assigned.
-
Timely investigation, analysis, and reporting all NYPORTS, ensuring that the regulatory requirements are met for root cause analysis, database tracking and generating data for the Director of Patient Safety & Risk Management, other departments, clinical chiefs, and the Medical Director and the Board of Trustees.
-
Maintains current knowledge of the reporting requirements promulgated by the New York State Department of Health (NYSDOH and OMH). Disseminates new information, regulations, policies and procedures to key administrative personnel within the healthcare organization, evidenced by review of submitted materials.
-
Applies the NYPORTS criteria to ensure proper reporting and follow up (RCA). Alerts the Department Director of any events requiring immediate attention, as evidenced by direct observation.
-
Works collaboratively with the Director of Patient Safety & Risk Management and other designated department staff to identify and track events, which are related to NYPORTS and EMTALA, other appropriate entities, as evidenced by review of daily work.
-
Responsible for the oversight of corrective action plans to NYPORTS/ EMTALA and/or
NYSDOH/OMH/ CMS findings as evidenced by direct observation. -
Evaluates trends and patterns related to the NYPORTS program and makes recommendations for improvement, as evidenced by review of reports and recommendations.
-
Review incident reports promptly and ensure investigative findings are complete as appropriate relative to the significance of the event.
-
Track and trends incident reports to identify safety issues and concerns throughout the organization
-
Make recommendations for Root Cause Analysis and Failure Mode Effect Analysis on safety issues and noted trends
-
Communicate in a timely manner significant safety event findings.
- Crosswalk incident reports and issues reported in the daily safety huddle to assure accuracy of report and determine time line for which investigation should be completed.
- Reports and presents relevant findings to organizational leadership; keeps organizational leadership and malpractice carriers informed of issues.
- Completes reports, with analysis, for the Board of Trustee meetings, Performance Improvement Board Meetings, Quality Management Council, Safety Action Council, the annual report and the annual Safety Report.
- Performs chart reviews as required 100% of the time, as evidenced by direct observation.
-
Attends assigned morbidity and mortality conferences for the purposes of identifying NYPORTS and understanding the outcome of discussion surrounding potentially compensable events, as evidenced by direct observation.
-
Performs literature search as requested in response to organizational issues and events, as evidenced by review of literature search results.
-
Completes on-call duties as assigned for Risk Management.
-
Serves as an expert resource for new risk management, quality management, legal affairs and similar staff within the organization and the network.
- Works closely with Senior Leadership and the Patient Safety Officer to continuously improve safety for patients and staff.
- Proactively explores potential system failures using the FMEA process.
-
Monitors viability and effectiveness of risk assessment plans.
-
Educates staff at all levels, including residents and physicians, in areas pertaining to risk and safety.
-
Works within multidisciplinary teams to design and promote error prevention programs.
-
Develops and presents in-service education related to risk management and safety topics, including participation in the CGME program for resident education.
- Establishes a positive working relationship with the Medical Director and Department Directors in review, investigation, and analysis of events requiring review, as evidenced by feedback and direct observation.
-
Verbal and written communication is professional, concise, and easy to understand, as evidenced by direct observation and feedback.
-
Understands the role and responsibilities of individual members of the health care team and interacts effectively and sensitively 100% of the time, as evidenced by feedback and direct observation.
-
Attends committees and teams as a representative of Risk Management, establishing positive working relationships with other committee/team members, as evidenced by feedback and direct observation.
- Willingly accepts and completes special assignments as required, as evidenced by direct observation.
-
Routinely reviews the NYSDOH/ NYPORTS/ EMTALA website and manual and other areas to maintain a current knowledge base on these subject areas.
-
Attends educational programs offered through such organizations as HANYS, VHA, MLMIC, CHART and so on to obtain current information regarding accreditation and regulatory activity.
-
Completes all required mandatory in-services, as evidenced by review of completion certificates.
-
Suggests organizational strategies and initiatives as a result of knowledge obtained through continuing education, as evidenced by review of suggestions received.
-
Does not discuss patient information except as necessary in the performance of the job 100% of the time, as evidenced by direct observation and feedback
-
Ensures patient information is not accessible to unauthorized individuals 100% of the time, as evidenced by direct observation of daily work.
-
Provides answers or offers guidance regarding risk management questions posed by members of the health care team, as evidenced by direct observation and feedback.
-
Utilizes Department Director as a resource when necessary.
-
Informs appropriate personnel immediately of serious occurrences or events.
-
Performs other duties as requested and observed by supervisor or manager
Education:
-
4 Year / Bachelor's Degree in Nursing, preferred
-
2 Year / Associate Degree or Diploma Nursing program, required
Experience:
-
Minimum 3 years of Acute Care Nursing experience, required
-
Plus 1 year of the following experience, required
-
Quality Management (RN)
-
Risk Management
-
Performance Improvement (RN) including unit specific projects
-
Leadership experience (including charge nurse, ANM, House Supervisor, etc.)
-
Minimum 1 year experience with database management systems, required
Licensure/Certifications:
-
Current NYS License as a Registered Nurse, required
Skills:
-
Communication
-
Analysis & Evaluation
-
Reading/Writing/Comprehension
-
Data Management
-
Computer Skills
Physical Requirements:
-
Sedentary Work - Exerting up to 10 lbs of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking or standing are required only occasionally, and all other sedentary criteria are met.
-
Occasional grasping, standing, walking
-
Constant hearing, talking, typing/clerical/dexterity, seeing/monitor/computer use
Hazards:
-
Occasional bodily fluid/bloodborne exposure
Working Conditions:
Travel:
-
Extensive Travel - you should expect to travel every week
