Regulatory, Compliance and Risk Prevention Coordinator

Job Description Summary

Under the direction of the Executive Director of Risk Management, the Regulatory Compliance, and Risk Prevention Coordinator will support the organization-wide regulatory compliance, patient safety, and risk prevention program.  This role will direct others within the facility towards process improvements that will support regulatory readiness and the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes.  This individual provides the Risk Prevention Department with administrative support, including data abstraction and management, and project coordination support for projects and initiatives. This individual will promote the hospital’s culture of safety via implementation of the principles of collaborative just culture and high reliability™.  

Job Description

Job Responsibilities:

1 - Use clinical expertise to identify and evaluate activities or events occurring within the Hospital that have the potential to lead to patient harm and/or which represent opportunities to improve the safety of services provided
   a - Regularly review safety event reporting and other patient safety/risk management data to identify trends for 
    quality improvement purposes.
   b - Participate in event investigation in collaboration with appropriate local leaders.
   c - Maintain appropriate documents/reports/reviews demonstrating event review status and results
   d - Demonstrate a high degree of professionalism when working with staff involved with adverse events, 
    promoting collaboration and a just culture.
   e - Actively participate in other committees and workgroups to review identified trends and develop sustainable 
    action plans
   f - Make recommendations for enhancing methods used for identifying and evaluating activities or events that 
    could lead to patient injury
   g - Produce and present reports and presentations utilizing various applications and/or multimedia systems 
    related to patient safety education and patient safety activities

2 - Provide effective support for conducting patient safety/clinical risk assessments and adverse event reviews, including collaborative risk reviews and implementation of effective corrective action plans
   a – Provide administrative and project management support to internal committees, as directed
   b - Conduct collaborative risk reviews, including development and implementation of sustainable corrective action plans
   c - Conduct patient safety assessment using information gleaned from internal data trends as well as from 
    published patient safety literature
   d - Review and analyze medical records to determine completeness and accuracy of documentation utilizing 
    sound documentation standards
   e - Monitor and ensure completion of action plans with key stakeholders and team members
   f - Collaborate with Quality Management and/or other colleagues to support and assist in the implementation of 
        performance improvement plan initiatives arising out of collaborative risk reviews
   g - Utilize a self-motivated approach to individual assignments as well as departmental/program needs
   h - Support and participate in ongoing organizational needs assessments for patient safety and clinical risk 
    management and regulatory compliance, including but not limited to the Joint Commission, Board of
Registration in Medicine, and Department of Public Health.
   i - Ensure cases are reported to the Joint Commission, Board of Registration in Medicine, and Department of 
    Public Health, as required
   j - Maintain up-to-date knowledge of existing and proposed patient safety related regulatory agency standards

3 - Demonstrates technical expertise in the areas of regulatory compliance, patient safety and clinical risk management and provide consultative assistance to individuals or groups as necessary
   a - Continued learning and development around advancements in medical care is demonstrated by staying 
    abreast of current literature and practice in patient safety and clinical risk management
      b - Monitor and disseminate patient safety standards, regulations, articles, etc. to the appropriate departments 
    within the Hospital

4 - Leadership & Training/Development: Educate and colleagues and medical staff in the organization on the system based

causes for medical errors and other issues related to patient safety and clinical risk management
   a - Provide regulatory compliance, patient safety and risk management educational programs to hospital 
    colleagues and medical staff.  Topics to include, but not limited to, the event reporting process, teamwork, 
    patient safety science concepts, effective communication and documentation skills, regulatory updates 
    related to patient safety and risk management
   b - Support process to communicate, plan for, monitor and evaluate new developments in patient safety/risk 
    management involving key staff from all relevant areas

5 - Technology and Learning
   a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and 
    procedures that continue to develop in their role and throughout the organization
   b - Embraces technological advances that allow us to communicate information effectively and efficiently based 
    on role

Job Requirements:
Minimum Education - Preferred
Bachelor’s degree preferably in health care related field.  Master’s degree desired.
Minimum Work Experience:
Minimum hospital experience of 3+ years required, with experience in patient safety, quality improvement, and/or risk management preferred.
 

Knowledge, Skills and Abilities:

• A thorough understanding of the principles of just culture

• Proficiency with Microsoft Word, Power Point and Excel required 

• Ability to abstract, collate and analyze data

• Ability to perform research regarding complex regulatory requirements

• Ability to work independently and collaboratively as a team player

• Ability to apply judgment and make informed decisions

• Excellent organizational skills with attention to detail and accuracy

• Excellent interpersonal and communication skills

• Ability to foster effective working relationships 

• Ability to interact in a positive, professional manner with colleagues, departments, vendors, and patients

• Ability to make effective oral presentations and prepare concise written reports for a variety of audiences

• Ability to plan, organize, prioritize, work independently and meet deadlines

• Effective project management skills; adept at complex project planning and management

• Ability to multi-task and effectively manage competing priorities

• Ability to translate and articulate complex requirements into terms easily understood by colleagues and providers at all levels of the organization

• Ability to develop and implement training curriculum for adult learners