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- Assess the current state of patient safety and staff awareness within the organization
- Collaborate on proactive patient safety initiatives
- FMEA
- RCA
- Safety Culture
- Just Culture
- Design, implement, and maintain educational programs on risk management and patient safety related topics

- Promote a culture of patient safety through education, policy development, and standardization of processes
- Educate providers, staff, employees, patients and families on the role of patients and families in improving patient safety and reducing risk
- Coach physicians, leaders, managers, and staff on appropriate disclosure methods and processes
- Participate in critical incident debriefing

- Participate in the development of corrective action plans and supervise follow-up of recommended improvements
- stemming from risk exams
- audits and investigations of reported incidents
- Provide guidance to staff regarding any of the following:
- disruptive patient, family member and/or visitors
- informed consent
- substitute (Surrogate) Decision Makers
- minors consent
- release of information
- law enforcement
- subpoenas
- attorneys
- search warrants
- abuse allegations
- advance directives/orders for life sustaining treatment
- Manage an incident reporting and data analysis system for patient safety, patient complaints, and other risk events
- Provide risk management consultation for specific ethical dilemmas
- Maintain awareness of patient safety initiatives occurring locally and nationally
- Review documentation and assist providers/staff with appropriate documentation to mitigate risk

- Manage a broad comprehensive insurance program including such activities as captive management
- insurance
- insurance purchasing
- insurance consulting
- administering self‐insured coverages
- managing or coordinating the management of claims for all lines of insurance

- Oversee the investigation of accidents or circumstances that could lead to financial loss
- professional
- institutional
- general liability
- product liability

- Analyze historical loss experience; address trends
- Develop enterprise risk financing strategies to address the organization's areas of exposure
- general liability (GL)
- professional liability (PL)
- cyber liability

- Provide recommendations to reduce risk in contracts, ensuring adequate controls and obligations for insurance coverage are appropriate to the risk
- Ensure timely reporting of incidents according to insurance policy language

- Promote compliance with federal and state laws and regulations through policy development, guidance, or education
- Promote compliance with federal and state laws and regulations governing patient confidentiality through policy development
- guidance
- education including protected health information (PHI)
- Promote compliance with federal and state reporting requirements through policy development, guidance, or education
- abuse of vulnerable populations

- Promote compliance with federal and state reporting requirements governing violence in the workplace through policy development, guidance, or education
- Promote compliance with federal and state regulations/organization policy regarding the investigation and resolution of patient complaints or grievances through policy development, guidance, or education
- Collaborate with other departments by preparing and conducting quality and/or risk exams to maintain a constant state of accreditation readiness

- Promote compliance with laws and regulations governing involuntary detention of patients through policy development, guidance, or education
- Promote compliance with the requirements of the following federal acts/regulations through policy development, guidance, or education:
- Centers for Medicare and Medicaid Services (CMS)
- Emergency Medical Treatment and Active Labor Act (EMTALA/COBRA)
- Health Insurance Portability and Accountability Act (HIPAA)
- National Practitioner Data Bank (NPDB)
- Safe Medical Device Act (SMDA)

- Design a risk management data collection/analysis system to ensure timely reporting and monitoring of:
- device reporting and tracking logs
- regulatory inquiries
- Collaborate in the development of the organization's regulatory compliance plan to ensure workforce compliance of all applicable accreditation standards
- Promote, in partnership with Patient Safety and Medical Staff departments, programs that address provider and staff behavioral issues are culturally, legally and psychologically sound and non-discriminatory
- Participate in the development of responses to questions from regulatory and licensing agencies, and insurance companies

- Collaborate with leaders and security personnel on workplace violence prevention
- Conduct risk exams to identify exposures related to new and existing services and enterprise‐wide services
- Establish a method for planning, evaluating, selecting, management, and on‐going evaluation of enterprise wide event reports of harm or near‐harm incidents
- Supervise and develop risk management staff

- Develop/maintain risk management department specific policies and procedures and modify as required
- Coordinate risk activities for the organization
- Develop annual institutional goals for the risk program/department
- Evaluate the effectiveness of risk management activities
- Develop policies and procedures for acceptance of legal documents
- summons
- complaints
- subpoenas
- court orders

- Support patient safety committee meetings by collecting and formulating relevant information to facilitate decision-making process
- Participate in professional association activities
- Understand the peer review, credentialing and privileging process
- Provide education/in‐service for staff, patients, families, communities on patients rights
- end of life decisions

- Collaborate on the development of policies and procedures which provide direction to the organization on Topics which have a significant degree of risk
- Privacy
- Informed Consent
- Infection Prevention
- Documentation
- Telemedicine


- Maintain data collection and analysis systems including elements of reports of Potential Compensatory Events (PCEs), open and closed claims and loss runs
- Notify carriers and/or third-party claims and litigation department or administrators of potential compensatory events or real claims
- Participate in claims management activities
- assignment of counsel
- setting loss reserves
- respond to discovery requests/interrogatories
- preparation and attendance for depositions
- mediation
- arbitration
- trials
- evidence/record preservation and management
- review and approve legal expenses

- Participate in evaluating claims to determine exposure to organization and the appropriate method for resolution
- Inform administration of high exposure cases and aggregate claims experience, including any impact to the risk financing program.
- Manage and maintain all information related to a potential or real legal case under attorney/client privilege and protected from discoverability
- Manage the response to service of process and notify appropriate parties of such service
- Support insured defendants through all phases of the litigation process