MAJOR DUTIES: Serves as MEDCEN Chief, Patient Safety and Risk Management Service, responsible for implementing, coordinating and administering the hospital Risk Management program with additional responsibility for designing, and overseeing the Patient Safety program in a 198 inpatient bed 28 ambulatory care bed 25 outpatient clinic regional Medical Center with Level 1 Trauma designation. 1. Supervises the Patient Safety Manager, the Claims Coordinator/Data Management Specialist. Assigns work to subordinates based on priorities, difficulty of assignments, and the capabilities of employees. Provides technical oversight. Develops performance plans, evaluate work performance of subordinates, and provide recommended ratings of record. Interview candidates for subordinate positions; recommend hiring, promotion, or reassignments. Takes disciplinary measures, such as warnings and reprimands. Identifies developmental and training needs of employees; provide and/or arrange for needed development and training. 2. Performs an investigative role. Independently reviews all actions from all sections of the MEDCEN which may be determined to be a risk management issue. These actions come to the attention of the Chief, Patient Safety and Risk Management Service as DA 4106 Unusual Occurrence/Risk Management reports, claims filed with the Staff Judge Advocate, various committee referrals, occurrence screens, concurrent reviews, peer/medical record reviews; and DCCS/QI investigations to include sentinel event notification. The review process will include a review of clinical processes for which advanced clinical nursing skills is required. All serious adverse events, whether or not they are compensable, will be promptly investigated by priority as determined by the Chief, Patient Safety and Risk Management Service in collaboration with the Chairperson of the Risk Management Committee and/or Deputy Commander for Clinical Services. Findings and recommendations for action are reported to the designated committee. When equipment is involved, ensures the equipment is removed from service and inspected by a qualified employee to determine whether a malfunction or design flaw led to the incident and if an independent appraisal is necessary. The Chief, Patient Safety and Risk Management Service shall take a leadership role in conducting the root cause analysis for each sentinel event, reporting the findings and recommended plan for correction to the Command. The Chief, Patient Safety and Risk Management Service ensures that all sentinel events are reported to MEDCOM and The Joint Commission as required. Provides analysis of hospital processes and data. Using nursing skills, knowledge of administrative and clinical processes oversees activities at the direct patient care level and at the patient care support level to assist all facility staff in reducing the risk of adverse outcomes. Identifies practices, procedures, equipment, and supplies that may contribute to a process variance and/or patient injury and communicates these findings to relevant personnel. Based on knowledge of clinical disease processes, medical treatment processes, and hospital practices, investigates cases from multiple data sources, to include inpatient and outpatient records, incident reports, infection control data, length of stay and summaries of complications, the Chief of Patient Safety and Risk Management Service determines the quality and appropriateness of patient care and deviations from recognized standard of care. Determines if further review is required and selects the avenue for further review to achieve a definitive resolution. Advises the Chairperson, Risk Management Committee and/or Safety Committee and/or Deputy Commander Clinical Services of the outcome and makes recommendations for further action needed. Follow-up actions may include additional internal peer review, referral for external peer review, referral to an appropriate committee, a Serious Medical Incident Report to the US Army Medical Command and the Office of the Surgeon General, or notification of the Staff Judge Advocate of a potential claim. 3. Collaborates with the Physician Chairperson of the Risk Management Committee to plan, coordinate, implement and evaluate the ongoing effectiveness of the Risk Management program, facilitating the hospitals patient care mission and ensuring quality patient care within the framework of established policy, standards of care, standards of practice and regulatory requirements. Using clinical nursing and administrative expertise, is responsible for risk management review activities for both inpatient and outpatient care in support of the Risk Management and Patient Safety programs. Analyzes data to identify systemic problems and provides feedback, based on published national standards of medical treatment that can be used for educational purposes to reduce or prevent undesired outcomes and financial losses to the MEDCEN. Advises the clinical and non-clinical Department Chiefs and their quality coordinators about risk management and patient safety issues. Reviews the overall effectiveness of the Risk Management program at least quarterly and the Patient Safety program at least annually, reporting to the MEDCEN Executive Committee. Serves as a standing member on numerous department and hospital level committees. Provides academic and professional instruction to students and all facility staff. This scope of responsibility requires intensive analysis of clinical processes utilizing nursing skill sets. Utilizes knowledge of current practices and standards in risk management, attentive to the latest changes and/or practices that impact on the MEDCEN to design MEDCEN program to ensure compliance Joint Commission, MEDCOM and DOD(HA) requirements. Implements risk management program ensuring practices are in keeping with requirements. Assesses the Risk Management standards and practices throughout the facility and its outlying clinics and initiates changes where needed to assure compliance with The Joint Commission,, nationally accepted practices, MEDCEN, MEDCOM and DOD(HA) requirements and policy. 4. Manages Risk Management database, analysis and reporting of data. Develops and maintains a data base to record data accumulated from the Risk Management program on types of incidents, locations of occurrences, providers involved, patients involved and treatment outcomes. The Chief, Patient Safety and Risk Management Service systematically analyzes this data and develops meaningful reports on a quarterly basis, noting adverse trends and unacceptable variance, by using charts and graphs. Reports this information to the Executive Committee, Risk Management Committee, Safety Committee, Patient Safety Committee and/or Quality Improvement Committee. Makes recommendations for improvement. Manages Claims. Upon receipt of a copy of a malpractice claim, reviews the medical records to identify the healthcare providers involved for immediate notification and initiate the peer review process. Submits initial DD 2526 to MEDCOM. When peer review process is completed, forwards the case to the Risk Management Committee. Maintains ongoing status of each case being reviewed within the risk management arena. Coordinates and facilitates the Risk Management Committee. Responsible for preparing the agenda for the Risk Management Committee meetings. Collects and assembles all case responses, pertinent medical records, and all other documents/evidence pertaining to each case. Ensures all necessary documents are distributed to each committee member prior to the Risk Management Committee meetings. Educates committee members on committee activities and due process. Coordinates with the recorder for all actions needed prior to the committee meetings. Assists the Physician Committee Chairperson by reviewing and briefing the Chairperson on the status of each case. The review and analysis of these complex clinical cases requires clinical nursing expertise and judgment. Reviews the draft of the committee meetings minutes, prepared by the recorder, to ensure accurate reporting of the discussion and follow-on actions are clearly delineated prior to forwarding the minutes to the Chairperson. Prepares all actions directed by the Risk Management Committee to include the reporting of negative case outcomes to the Medical Staff Executive Committee. Advises the Commander, DCCS, and Chairperson, Risk Management Committee on the status of cases under investigation, claims filed and settled, and of all negative outcomes identified. Upon completion of the peer review process, the Chief, Patient Safety and Risk Management Service is responsible for the completion of a DD 2526, Case Abstract for Malpractice Claim and forwards this through the chain of command to the Office of the Surgeon General. 4. Provides guidance and supports hospital departments. Participates in providing advice and assistance to the clinical and non-clinical departments in identification and investigation of risk management and patient safety problems, designing assessment methodologies, and preparing appropriate reviews. Participates in planning, organizing, and conducting training of service, ward, clinical, and support personnel in risk management techniques, criteria development, data retrieval and display, data analysis, preparation of risk management studies, and confidentiality of data used in the Risk Management program. Reviews all medical record requests from attorneys to determine if reason for request is potential litigation. Serves as the clinical resource for patient representative, congressional inquiries, safety, and inspector general complaints in the identification and investigation of risk management problems. Serves as the point of contact within the MEDCEN for arranging, scheduling, and coordinating interview of MEDCEN personnel by the Medical Claims Judge Advocate, Department of Justice or representatives of the US Army Claims Service. 5. Oversight of the Patient Safety Program. Responsible for designing the patient safety program and oversight of its implementation. Maintains knowledge about current practices and standards in patient safety, and keeps abreast of the latest changes that impact on the MEDCEN. Together with designated staff members, ensures that all Joint Commission and MEDCOM standards are met. Utilizing nursing skills sets and knowledge of clinical processes ensures that an ongoing, proactive program for identifying risks to patient safety and reducing medical/healthcare errors is defined and implemented. This requires annual review of the program with ongoing refinement. Identifies high-risk processes for proactive risk assessment, based in part on information published by Joint Commission that identifies the most frequently occurring types of sentinel events and patient safety risk factors. Submits required monthly and quarterly reports to MEDCOM on a timely basis. Analyzes aggregate data, submits recommendations to the Patient Safety Committee. Ensures that hospital leaders and staff have an integrated approach and participate in the hospital-wide patient safety program. A significant focus is placed on proactive identification and management of potential risks to patient safety; i.e. preventing adverse occurrences, in addition to responding to variances and adverse outcomes. Manages the Risk Assessment and Patient Safety Committee, ensuring that all information presented is statistically correct, easily understood with the initial analysis complete. Performance Improvement. Utilizes an in-depth knowledge of performance improvement to design improvement activities, monitor and track corrective actions to resolve problems/variances. Develops process improvement tools to track the implementation and practice of risk management and patient safety policies and procedures. Incorporates available information from within the organization and from other organizations about potential risks to patients to minimize the risks to patients affected by new or redesigned process, function or service. Performs other duties as assigned.