Massachusetts Veterans Jobs

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

Beth Israel Deaconess Hospital-Plymouth recognizes Integrity, Respect, Trust, Teamwork and Excellence as the Core Values of our organization. It is the philosophy of BID-Plymouth to follow the LEAN methodology in order to provide the full continuum of health care services and the best quality patient centered care.

Job Description:

This position provides leadership and is responsible for Hospital-wide implementation of the Patient Safety and Clinical Regulatory Compliance Program that aligns with the strategic initiatives of the BILH System. Additionally, this position directs and coordinates all hospital and specialty practice, risk management, patient safety, regulatory compliance, and patient relations requirements. This position will support cultural diversity by ensuring that the delivery of quality, equitable and culturally competent patient-centered care is provided; promoting and maintaining an inclusive work environment and culture that is respectful and accepting of diversity; and ensuring that cultural diversity and sensitivity training is part of new employee orientation on an on-going basis to meet the needs of the patient population served in the hospital.

Duties/Responsibilities:

Under the guidance of the Senior Director of Quality and Patient Safety, members of Senior Leadership and others as necessary work to promote a culture of Safety, Performance Improvement and High Reliability. This may include leading teams, providing training and similar duties in support of the hospital’s efforts to build a high-performance culture.

Risk- Oversee the Risk Management office for BID-P including all phases of actual and potential claims management. Identifies exposures to loss and analyzes the impact on the organization.

• Oversee and manage the internal Adverse Event reporting system as a critical element of the safety program. Ensures appropriate responses to Adverse Events to mitigate immediate threats to safety and address other serious issues.

• Collaborates with Nurse Directors, Managers, providers and other staff to keep all Hospital personnel informed regarding risk management and patient safety issues.

• Ensures that the Risk Specialists Investigate and monitor all hospital sentinel events and near misses within 72 hours of the event. Review and analyze event reports, conduct investigations and follow-up with appropriate management staff.

• Support, provide guidance, and assist providers with disclosure of an event when indicated.

• The Director will oversee the Risk Specialists as they lead Root Cause Analyses, Failure Mode Effects Analyses and apply Performance Improvement methodology in order to improve error prone systems and processes as part of a system-wide effort to promote high reliability. Specifically, the Risk Specialists will conduct root cause analyses in response to near misses, serious adverse events, and sentinel events to determine the causes of these events; assist in developing corrective action plans and improvement initiatives to eliminate these causes; and assess risks of new programs.

• Conduct Risk Management orientation training. Develop and make recommendations for educational Risk Management programs based on needs assessment. Conduct educational activities for the staff and physicians to promote risk reduction strategies.

• The Director represents the hospital as an agent for service of legal process, coordinates activities such as record requests, assists legal counsel with malpractice, hospital litigation and depositions.

• The Director will oversee the Risk Specialists for referral of lawsuits, claims and potential claims to CRICO, the hospital's liability insurance carrier, for monitoring, investigation or defense and completion of necessary claims paperwork. Work with staff, physicians, insurance companies, attorneys and any other parties who may be relevant parties in a malpractice or liability claim.

• The Director will oversee the Risk Specialists as they provide ongoing support to CRICO and hospital counsel in the litigation process: contacts hospital employees for depositions, assists in obtaining answers to interrogatories, requests for production of documents and records from multiple BID-P sources.

• Works with the Office of General Counsel as necessary.

• Collaborate with our Clinical Services and Medical Staff Officers with tracking/trending of adverse outcomes and medical malpractice claims in order to improve quality of care and advance patient safety.

• As a member of the Division of Quality and Patient Safety, the Director is a key resource in the planning and implementation of efforts to create highly reliable clinical systems at BID-P. Participates in and promotes a mechanism of continuous process improvement that betters patient care outcomes over time.

• Reports outcomes periodically to Administration and other bodies as required/ requested on the institution’s risk experience and efforts to optimize the experience in the future.

• Serve as the primary contact for BID-P to the Massachusetts DPH, the Boards of Registration in Medicine and Nursing, and other regulatory agencies as needed.

• Ensure timely Management and follow up on equipment recalls along with Identification and development of information related to equipment failures to ensure compliance with the reporting requirements of the Safe Medical Devices Act.

Regulatory Requirements- Assesses hospital compliance with accreditation standards and regulations related to clinical care in collaboration with leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance. Coordinates hospital clinical compliance activities to ensure that hospital is in compliance and has an integrated, consistent plan for continuously complying with all required CMS, DPH, Mass Health regulations and Joint Commission standards.

• Provides direction to hospital leadership in order to maintain readiness for all random and/or unannounced surveys by The Joint Commission, DPH and other regulatory agencies.

• Proactively educates leadership and staff regarding new regulatory requirements related to quality and patient safety.

• Leads and coordinates, all regulatory surveys. Completes and submits corrective action plans. Implements and monitors corrective action plans and assists hospital leadership in obtaining compliance.

Specialty Practices patient safety and quality program- Build and maintain the Safety and Quality program for the specialty outpatient practices.

• Safety program – event reporting, trending data/issue identification, follow up and education – corrective action plan development and implementation

• Patient Satisfaction survey implementation, data retrieval, analysis and action plan to improve

• Patient Relations program

Patient Relations- Oversight of the hospital wide patient relations program and ensure compliance with regulatory requirements for complaints and grievance management.

• The Director will oversee the Patient Relations Manager who is responsible for the Complaint and Grievance response function. Assure that this function is timely in responding to patient concerns and does so in a clear, respectful and compassionate manner.

• Chair of the PFAC

• Chair of the Patient Rights Committee

• Press Ganey – HCAHPS results and Performance improvement plan development and implementation

Education/Experience Required:

• BSN preferred with Current Massachusetts RN license

• Masters Degree in Nursing, Healthcare Management or related field. Preferred

• A minimum of 5 years of experience in Healthcare Risk Management or Patient Care Management required

• Risk Manager experience in healthcare setting preferred

• Proven ability to function independently and communicate effectively at all levels of an organization required.

• Must be able to demonstrate knowledge and experience in fundamentals of performance improvement, patient safety and risk management (Root Cause Analysis, Failure Modes Effects Analysis, Disclosure, basic statistics, run charts, control charts etc.)

• Must have strong organizational, analytical and computer technology skills (Word, Excel and PowerPoint); Database experience preferred.

• Strong written and verbal communication skills

• Good listening skills

• Comfortable in emotionally charged settings with patients, families and / or staff

• Experience in conflict resolution

• Prior experience in direct responsibility for regulatory affairs and claims management strongly preferred

Registration/Certification:

• Certification in risk management (CPHRM) or obtained within the first five years

FLSA Status:

Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled