Responsible for evaluation, oversight and management of patient safety, risk management, patient relations and regulatory standards throughout the enterprise. Projects an image of professionalism in communication, appearance and conduct. Supports the hospital mission and values through activities to protect all assets and resources of the hospital. Patient relations-oversees patient grievances in an
appropriate and timely manner. Risk management/Protects the rights of the patient, the clinical and medical staff of the organization. Utilizes critical thinking to identify untoward trends and collaborate for resolution and prevention. Protective of confidentiality of information. Patient safety/regulatory-acts as a resource for the organization regarding issues of patient safety and rights, regulatory standards and create benchmarks for patient safety and identify strategic initiatives to support the organization’s goals.
• Responsible for the development, implementation and operations for the Risk Management, Regulatory Compliance Department which includes the following entities:
Accreditation/licensure, risk management, compliance, patient representation, event research, Root Cause Analysis (RCA).
• Provides leadership, administrative direction, oversight and implementation support for risk management, regulatory strategies, initiatives and processes that support optimal performance in the areas of fiscal and qualitative outcomes, patient safety, regulatory and accreditation functions.
• Provides leadership for Sentinel/Clinical Event process-identification and prioritization of cases with appropriate leadership, case write up and summation, patient complaints, complications, nursing peer review.
• Coordinate Medication Error Reduction Plan in collaboration with the Medication Safety Team.
• Oversight and coordination of regulatory survey process including completion of 2567 corrective action plan, submission of plans of correction for accrediting agency, application submission and compliance response.
• ISO compliance support and coordination with internal audit process.
• Responsible for pro-active policy and procedure development and revisions to meet regulatory and safety requirements.
Job Behavioral Competencies
• Applies strong interpersonal relations and communication skills to provide internal consulting on quality of care/evidence-based, reliability of care, patient safety from internal and external resources as well as regulatory issues.
• Exhibits quality in leadership skills, customer services and process improvement. Oversees and supports the functions of the Sentinel/Clinical Event Committee and patient safety/rights initiatives. Risk management
• Facilitates conflict resolution in regulatory and requirements regarding patient grievances, (subpoena, testifying at hearing or other court appearances), and mandated reporting of events.
• Develops supportive relationships with the various departments in order to establish a consistent and supportive process throughout the organization.
• Responds to patient and family grievances and concerns per regulatory standards.
• Acts as a support and consultant to staff and physicians with patient and family grievances and concerns.
• Provide full and succinct initial investigation following notice of legal action in order to provide proper oversight legal counsel services.
• Includes CEO and liability counsel in all negotiations and all settlement decisions.
Quality and Service
• Partners with the Compliance Office, Quality Management, clinicians and other stakeholders, to implement a comprehensive patient safety and regulatory compliance program including on-going safety and regulatory assessment using internal and external resources, and identification, and identification and resolution of adverse events, and root cause analysis for the prevention of adverse events.
• Acts as a resource and active committee member to Medication Safety, Nursing Peer Review, Quality Management, Pharmacy and Therapeutics, and other committees as assigned.
• This position will ensure that all regulatory compliance requirements and patient safety endeavors are achieved.
• The director will collaborate with all stakeholders to develop a safe and regulatory compliant environment through an environment resulting in quality, efficiency, safety, satisfaction and value.
• The position will have oversight of data collection, analysis, reporting, improvement plans, and follow-up related to safety and regulatory activities.
• Develops patient safety, survey readiness and regulatory compliance strategies, manages and leads process improvement initiatives.
• Identifies opportunities for improvement regarding patient safety and regulatory compliance.
• Partners with medical staff to develop and implement patient safety initiatives.
• Develops a collaborative professional relationship with medical staff to support evidence-base patient safety measures to reduce risk and increase quality.
• Collaborates with key organizational departments and stakeholders to ensure nursing practice is
consistent with hospital wide standards.
• Recommends policies when and where appropriate.
• Oversees process to review and revise Nursing Care policies to meet regulatory standards.
• Comply with annual health evaluation.
• Attend required department and hospital meetings.
• Maintain CPR and other certifications per hospital policy.
• Maintain current license, certification, and registration
• Complete competencies per organization/department requirements.
• Perform job within hospital/patient safety standards (e.g. codes, fire, disaster, etc.)
• Perform job in safe manner to avoid injury to self and others, illnesses, and exposure to blood/body fluids, wear personal protective equipment, and uses appropriate safety products.
• Maintain a personal dress standard in keeping with hospital/department policy and wear approved name badge.
• Demonstrate knowledge of and practices the hospital and department policies and operating procedures. This knowledge may include the use of specialized instrumentation, Quality Control requirements, and preventative maintenance.
• Demonstrate knowledge of and practices the standards outlined in Hoag’s Code of conduct as well as additional regulatory or compliance policies applicable to their job responsibilities. Take timely action in response to any matter which raises a suspicion that a violation of law or Policy has occurred.