Risk Management & Patient Safety Manager

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Adventist Health System
May 22, 2020
Mansfield, Texas
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United States
Mansfield, TX

Risk Management & Patient Safety Manager at AdventHealth
Date Posted: 5/20/2020

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Mansfield, TX

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Risk Management


1 - Day

Texas Health Huguley Hospital

Job Description
Manager of Risk Management and Patient Safety -  Texas Health Mansfield- operated as joint venture between Texas Health Resources and AdventHealth

Location: 2300 Lone Star Road; Mansfield, TX

Top Reasons to Work at Texas Health Mansfield; Mansfield, TX

•         Join a family of caregivers focused on whole-person health and committed to making communities healthier.

•         Provide wholistic care for patients that extends to the spiritual level by praying with patients and families.  Chaplains are available to meet with patients, families and team members 24 hours a day, 7 days a week to provide spiritual support.

•         Help develop a brand new $150 million community hospital and medical office building that will provide services such as Medical/Surgical, ICU, Women’s Services, General Surgery, Orthopedics, Interventional Cardiology and Gastroenterology.

•         Grow in your career with AdventHealth, named in 2018 by Becker’s Hospital Review as one of the “150 Top Places to Work in Healthcare”.  AdventHealth has partnered with Texas Health Resources, named in 2019 as one of Fortune’s 100 Best Companies to Work For, to build Texas Health Mansfield, which is creating new opportunities for employment and professional growth.

•         Thrive in the Mansfield community, ranked by CNN/Money Magazine as #17 for “Best Places to Live”.  Mansfield is one of the fastest growing areas of North Texas, projected to reach more than 250,000 residents by 2023.  Future job growth over the next ten years is predicted to be 41%, higher than the national average of 33.5%.  Mansfield has top-rated schools, over 900 acres of parkland, quality housing, a historic downtown area, recreational opportunities for all ages, and a growing business community.

Work Hours/Shift:

Full Time

You Will Be Responsible For:

Leads Clinical Risk Management efforts

•                  Participates in the review of all high-risk clinical occurrences received within the organization through collaboration with the respective Director/Manager

•                  Investigate reports of any serious event involving actual or potential injury to patients or visitors to assess liability and probability of legal action

•                  Provide proactive and reactive safety initiatives including facilitating root cause analysis, apparent cause analysis, failure mode and effect analysis and Sentinel Event Alerts.  The information will be used to develop a process and plan for change that can be constantly monitored and evaluated for effectiveness

•                  Facilitates/conducts Root Cause Analysis (RCA) Teams. Organizes and provides leadership to the RCA teams and follows up on outcomes of RCA team results and recommendations

•                  Facilitates/conducts risk assessments to assess safety and liability exposure across the organization.  Utilizes proactive risk assessment tools, include Failure Modes and Effects Analysis (FMEA)

•                  Recommends and facilitates change to improve based on identified risks

•                  Facilitates the creation of an effective action plan in response to identified issues

•                  Oversees all reportable events and assists with the submission of this information

•                  Notifies appropriate leadership of potential litigious events

•                  Participate in facility committees related to quality of care, safety programs, medical/regulatory issues and accrediting standards

Manages Patient Safety and Regulatory Compliance efforts

•                  Maintains knowledge of national, state and local regulatory and accreditation requirements, as it pertains to the Texas State Statutes, CMS Conditions of Participation (CoP), Joint Commission (TJC) standards, and Healthcare Facility Accreditation Program standards, as it relates to the operations of Texas Health Hospital Mansfield

•                  Provides direction to ensure that clinical services are provided in accordance with safety standards established by these agencies

•                  Responsible for facilitating improvement efforts to ensure compliance with TJC and HFAP Accreditation and CMS Conditions of Participation by ensuring continuing survey readiness

•                  Conducts mock surveys and tracer activities across the organization on a regular basis

•                  Collaborates as directed to collect data (chart audits) to assess for compliance with National Patient Safety Goals

•                  Prepares results and/or summaries of data collection, including graphic presentation

•                  Conduct Focused Standard Assessment for accredited programs

•                  Communicates with and educates associates and medical staff on Joint Commission standards

•                  Communicates and facilitates necessary changes in order to remain continuously compliant with accreditation standards

•                  Serves as a resource for hospital identified programs seeking Joint Commission Certification and other accreditations

•                  Collaborates with other hospital leaders in developing, monitoring, reporting and analyzing accreditation efforts

•                  Proactively seeks opportunities/mechanisms aimed at continually improving patient care, processes and compliance

•                  Facilitates the creation of an effective action plan in response to identified issues

General Duties & Responsibilities

•           Responsible for follow through and oversight for completion and actions plans relating to identified issues, including follow up measures of effectiveness.

•           Is readily available for questions and handles requests in a courteous and respectful manner

•           Utilizes the Performance Improvement Model

•           Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicated.

•           Develops data reports for projects, committees, hospital departments, and medical staff departments as delegated

•           Utilizes statistical approaches, measurement techniques, and benchmark comparative data to develop quality reports

•           Participates in hospital-wide outcomes and quality improvement initiatives

•           Assists in efforts to improve and streamline the process and workflow of the department

•           Demonstrates the ability to set appropriate priorities.

•           Recognizes how absence impacts the functioning of the healthcare team and strives to minimize this effect.

•           When requested, is willing to adjust personal schedule in order to complete workload when necessary

•           Attends educational offerings as needed to promote continuous learning and support to department

•           Other duties as assigned

What will you need:

•         Microsoft Office proficiency

•         Excellent interpersonal skills to deal with challenging situations while maintaining strong supportive relationships

•         Effective communication skills, both written and verbally

•         Proactive attitude and seeks to remedy situations before patient care is impacted; takes responsibility for the overall quality of the facility

•         Collaborative workstyle

•         Bachelor of Science in Nursing

•         Minimum: 5 years of clinical nursing experience
•         Current unrestricted state of Texas RN license
•         Master’s degree preferred
•     3 years of healthcare accreditation or risk management experience preferred
•         CPHRM certification preferred

Job Summary:

The Manager of Risk Management & Patient Safety reports to the Director of Quality and Accreditation. The Manager of Risk Management & Patient Safety takes a leadership role in investigating reports of any serious event involving actual or potential injury to patients or visitors to assess liability and probability of legal action.  This professional conducts proactive and reactive safety analyses, including root cause analysis and failure mode and effect analysis to develop a process and plan for change that can be constantly monitored and evaluated for effectiveness.

The Manager of Risk Management & Patient Safety works collaboratively with all department leaders to ensure continuous readiness and compliance with all accrediting bodies and regulatory agencies, across the organization. This includes Joint Commission standards, Healthcare Facility Accreditation Program standards, and CMS Conditions of Participation.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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