Director, Patient Safey & Risk Management
Kaiser Permanente Mid-Atlantic (Montgomery County, Maryland)

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POSITION TITLE: Director, Patient Safety and Risk Management

PURPOSE:. Directs and leads the Risk Management/ Patient Safety Programs for the KPMAS Region, assuming the accountability for achieving outcomes related to minimizing, reducing, eliminating or preventing injuries or loss exposure within Maryland, DC, and Virginia service areas.  This position designs, implements and evaluates the KPMAS Risk Management/ Patient Safety Programs in consultation with the KFHPMAS and MAPMG leadership and staff. Ensures that the appropriate quality of care is provided to our members, patients, and employees.  As well as, aligns and integrates clinical risk management/ patient safety programs, processes and systems with Regional and organizational goals and objectives and within established clinical standards. 

 

“This position consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to the applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures. In addition, Regional leaders are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.”

 

ACCOUNTABILITIES:

Directs the Risk Management/ Patient Safety Program for the KPMAS Region, which includes the design, implementation, maintenance and oversight of a coordinated and direct referral of potential malpractice claims, significant events (SE), near misses, potentially compensable events (PCE), unusual occurrences or actual legal cases, including the tracking, trending, analysis, and regular reporting to the RQIC.Directs, develops and maintains an ongoing risk assessment and analyses of data trends as to the effectiveness of the Risk Management/Patient Safety Program.  This includes risk management database management and identification of opportunities for improvement, documentation of improvements taken and any follow-up monitoring that evaluates compliance and efficacy of the program.Provides Risk Management/Patient Safety consultation with all KPMAS staff and physicians, core hospitals, SNFs, and other contracted providers as related to KPMAS.  Ensures appropriate risk identification, risk prevention and injury/loss control systems and procedures are in place and function properly in all patient care delivery areas within the KPMAS Delivery System.Collaborates with other KP Regions and Program Offices Quality Department, to ensure that risk management strategies and systems are shared throughout the Region and the Program as much as possible.Directs, develops and implements an effective Risk Management/Patient Safety educational program for KPMAS staff and practitioners.  Provides CEU and CME in-services to all medical centers/ departments on issues pertaining to but, not limited to confidentiality, documentation, treatment of minors, depositions, informed consent, early resolution, and written correspondence to members, families, or next of kin, etc.Serves as a consultant to medical center facility, Regional, Program Office, and KPMAS staffs.  Assists staff in subpoena handling, including contacting attorneys and setting up processes for review.  Assists practitioners in developing responses to the Boards of Medicine and Nursing regarding concerns or requests for more information.  Advises and coaches other KPMAS Departments, medical staff, other practitioners in responding to members, families, or next of kin matters, providing the best advice to protect everyone involved and to support a early resolution of issues/ concerns.  Develop and continue to review and revise Risk Management/Patient Safety policies and procedures to assist staff and physicians in areas such as: required reporting, treatment of minors, violence in the workplace, informed consent, QRR/ UOR reporting, etc.  Co-chair of the Patient Safety/ Risk Management Committee, providing a leadership role in the development, oversight and implementation of an effective patient safety/ risk management program.  This includes the development of a committee charter, annual work plan, annual evaluation of the program, and quarterly reporting of the program’s efficacy, barriers, issues and accomplishments to the RQIC.Collaborates with Quality Management Senior Director in the preparation of the quarterly QHIC reports and/ or responses for the KFH/HP Board of Directors.Investigates and analyzes actual and potential risks/safety concerns on a proactive and preventive basis.  Conducts investigations of serious occurrences with the request from legal counsel in order to preserve information under the attorney-client privilege.  Facilitates in the root cause analysis of significant events in identifying risk potentials and corrective actions to address issues.Develops and implements rapid response mechanisms and situation management procedures for onsite patient and/ or member issues, i.e. process for disclosing unanticipated adverse outcomes related to the Patient Safety Program.  This includes response to KPMAS’ staff needs and requests in advising and assisting with the appropriate disclosure of unanticipated adverse outcomes to members and families.Coordinates supporting documentation and preparation of risk management activities in the survey process related to NCQA, MDQR, CMS, state and other regulatory standards.  In conjunction with the Medical Directors Quality Review (MDQR), assists in the assessment of the effectiveness of the region-wide risk management/patient safety programs, including the medical centers and service area risk management programs; reports findings to the quality oversight committees and revises the program plan as necessary.Develops, directs and implements an education program for orientation of all new clinical staff and physicians that covers many aspects of Documentation, Confidentiality, Informed Consent, Patient Rapport and Notification of the Risk Management/ Patient Safety Department etc.Develops and presents an annual report to the KFHP Board of Directors Quality Health Improvement Committee and the MAPMG Quality Committee that outlines the proactive Patient Safety/Risk Management risk reduction and loss prevention strategies that have been implemented during the previous year.  Establishes and maintains collaborative linkages with other functions throughout the Region, e.g., Patient Safety, Nursing, Member Services, Compliance, Environmental Health and Safety, Credentialing and Confidentiality Committees etc.

 

MINIMUM REQUIREMENTS –

Relevant Years of Experience: ·         Ten years of direct experience in the direction, management and analysis of patient safety/risk management data in health care/managed care fields required.·         Ten years of experience in the direct management and oversight of programs and staff required.·         Working knowledge of federal state laws and regulations, as well as NCQA requirements required.·         Demonstrated knowledge and experience in applying quality assurance regulations and initiatives required.·         Proficient in computer applications including Microsoft Office Suite required.·         Strong interpersonal skills, with good verbal and written communication skills required. ·         Skills in problem-solving and collaboration with other professions/ disciplines required.·         Demonstrated experience in implementing initiatives or projects required.

 

Education and/or Classes:

Master’s Degree in nursing or related health care field required.Advanced degree in risk management, quality, nursing, public health (epidemiology), or related field (significant additional relevant experience may be substituted for advanced degree) preferred.

 

License, Certification and/or Designation: 

Licensed RN or other health care discipline licensure required.Certification in risk management, quality or other health care competency required.