Serves as the Patient Safety Officer. Manages the hospital-wide risk management program and completes internal and external investigations related to patient/visitor incidents. Coordinates hospital-wide action plans and corrective actions with facility leadership. Assists with the credentialing process to ensure that the Joint Commission and other regulatory agency standards are met. Establishes the standards of documentation and trains clinical employees of the hospital.

Analyzes incident and other related performance indicator data utilizing available sources such as electronic data base systems, software, reports, literature, questionnaires, and charts for the purpose of establishing baseline performance and determining areas in need of quality improvement and/or risk mitigation

Performs daily, weekly and monthly Quality Assurance audits as scheduledCoordinate performance, and metrics for each Department with supervisory staffTrain and educate staff on hospital policy and procedures. Evaluate and detect emerging areas of vulnerability, report and collaborate on changes with leadership.Develop new hire orientation training materials including post-training tests