Legacy Health

Clinical Risk Managment & Quality Improvement Consultant

Job Location Silverton Medical Ctr campus
Position Status Regular Full-Time
Requisition ID
Quality And Patient Safety
Avg Hours Per Week
Pay Range
USD $39.12/Hr. - USD $58.30/Hr.
FLSA Status
Work Days
Mon-Fri, no weekends
Shift Length
Shift Start Time
Shift End Time


At Legacy, our mission is to make life better for our patients, our staff and the community. As part of that mission, we continuously review the quality and safety of our services, and we look for ways to build upon our existing strengths. If quality improvement and risk management are areas in which you thrive and you share our passion for helping others, you may be an ideal fit for this position.


This role supports Legacy Health’s clinical risk management, Continuous Quality Improvement (CQI), quality advisor functions, and patient safety activities in support of improvements in clinical practice, service quality, and regulatory compliance.


The risk management responsibilities are to provide expertise in identifying, mitigating and controlling losses related to patient and visitor injury, to maintain compliance with specified regulatory requirements including mandatory and voluntary patient safety reporting, and the control of related charges, and to promote patient safety. Related activities include partnering with clinical personnel in managing adverse outcomes, investigating incidents, recognizing, investigating and reporting potentially compensable events, and offering education, support and consultation to clinical personnel regarding clinical risk management issues and practices. Additional activities include facilitating root cause analyses, surveillance for and reporting events in compliance with LH policy and regulatory agency requirements, support of the investigation of patient grievances, real time risk management consultation, and support for medical staff peer review.  This individual participates in formulating policy and/or organizational change, with advice and approval from higher authority. Nursing licensure is required and nursing expertise is required for, and informs, all aspects of this role.


The quality Improvement role includes responsibility for supporting and guiding improvement efforts and projects through the application of Continuous Quality Improvement principles that support the organization in achieving top performance and maximizing outcomes for clinical practice, patient experience and process improvement. Works collaboratively and in cooperation with site and system teams on issues related to quality and patient safety outcomes. Helps to identify potential clinical and service issues that are at risk to stake holders. Supports a quality culture including teaching and training staff and leaders on Legacy Health improvement methodology.


This position supports Legacy Silverton Medical Center, which serves the heart of the Willamette Valley with a wide mix of services, many not typically available in a community hospital: CT scan (computerized tomography), nuclear medicine, echocardiography, family birth center and much more.



  • Partners with clinical personnel and leadership to manage and investigate adverse outcomes including those related to clinical error
  • Conducts or supports the investigation of and response to patient grievances alleging sub- optimal clinical care, in accordance with LH and regulatory requirements
  • Provides real time risk management consultation for LH employees and leaders and responds to professional liability questions posed by physicians, nurses, and other LH employees.
  • Supports the process of disclosure for medical errors
  • Facilitates root cause analysis investigation and the development of appropriate and effective improvement plans
  • Coordinates efforts to seek resolution to adverse outcomes as appropriate
  • Seeks to learn about, investigate and assesses liability and probability of legal action for notification of insurance carriers to assure coverage.
  • Reports to Manager those cases that need consideration for reporting to the professional and general insurance programs including the self-insurance program and excess carriers.
  • Reports to administration those incidents with claims potential; reports to higher authority any serious event involving actual or potential injury to patients, or visitors.
  • Recognizes, investigates, and prepares the reports for those cases that meet criteria for patient safety reporting to patient safety agencies Recognizes, investigates and works collaboratively with Patient Business Services to identify charges related to adverse events that should not be billed.
  • Coordinates review and response to complaints and quality of care concerns posed by health plans. 
  • Supports and uses systems for risk identification, investigation, and risk reduction; maintains a network of informational sources and experts; performs risk assessments of patient care practices and areas to access loss potential.
  • Informs leadership regarding occurrences, issues, findings, and risk management suggestions.
  • Maintains confidential risk management files and related data in a manner that supports compliance with LH policies, regulatory and governmental agencies, promotion of patient safety and effective claims investigation and management.
  • Works at the direction of the Manager of Risk Management, the claims manager and legal counsel to support the investigation, processing, and defense of claims against Legacy Health.
  • Recognizes, investigates, and prepares cases of general liability for referral to the claims process
  • May review and report on the claims history of the clinicians insured by Legacy Health System Insurance Company (LHSIC), in response to credentialing requests
  • Recommends ways to minimize risks through system changes and revisions to new or existing policies and procedures.  Participates on select committees related to provision of patient care and directed towards promoting risk management and patient safety.
  • Maintains awareness of legislative and regulatory activities related to health care risk management
  • Provides in-service training to Legacy Health physicians, nurses and others regarding their role in reducing liability exposures.
  • Reviews collated data to identify trends regarding incidents, and recommends corrective action to management
  • May support medical staff peer review
  • May have on-call responsibility
  • Other duties as assigned by the Manager, Risk Management


  • Project management accountabilities:  Serves as project management consultant to facilitate development, testing, implementation, and maintenance of Legacy Health System quality initiatives in a timely, effective manner. 
  • Assists in definition of project goals, team membership and resources, and maintains project timelines in conjunction with leaders.  Works to maintain positive group dynamics. 
  • Applies appropriate performance improvement tools and techniques to facilitate problem identification, adherence to project timelines, and effective use of resources.
  • Consultation services:  Provides consultation and education in CQI processes so that clinical practice improvement and service quality are enhanced. 
  • Facilitates the development of quality plans and relevant indicators to monitor performance on an ongoing basis and the development of action plans. 
  • Quality advisor responsibilities:  Participates as the facilitator and/or informal leader on process improvement teams and other quality forums.  
  • Applies Legacy problem-solving methods and CQI tools to guide process improvement efforts.  Selects, uses, and teaches CQI tools which correspond to the problem-solving process.  Facilitates the development of action plans to address identified opportunities for improvement. 
  • Utilizes knowledge of process improvement (flow charts, process observation, idealized design, best practices, use of leading indicators, and evidence-based literature, etc.) to facilitate simplifying and standardizing processes and clinical practice patterns whenever possible.
  • Works in conjunction with committee chairs and leaders to identify performance improvement strategies, develop agendas and prepare meeting packets. 
  • Hospital-specific accountabilities:  Supports performance improvement efforts at the hospital level by participating on site-specific Quality Councils, Leadership Councils, and Medical Staff Committees as requested.  Site Quality Representative participation may include presentation of hospital-specific outcomes data (patient satisfaction, SciHealth, Care Science, incident report trends, etc.) including presentations. 
  • Facilitates discussion of data analysis and the development of effective action plans that align with Legacy Health System strategic goals.
  • Data analysis and reporting:  Analyzes, interprets, formats, and presents quality (clinical and service) data for a variety of users.  Identifies services and/or cases for clinical studies.  Uses basic statistical techniques to analyze outcomes to determine special or common cause variation.  Applies expert knowledge to determine graphic or visual aids that best display data to support analysis and recognition of opportunities for improvement and problem-solving efforts. 
  • Focused study development:  Assists management/medical staff in formulating requests for data and supports development of prioritized studies that fully utilize electronic system databases and registries to address operational issues when available.
  • Designs data collection methodology including data definitions and study parameters before initiating focused studies.
  • NEO presentations: Presents overview of the Legacy Health performance improvement process, strategic goals, and patient safety initiatives to new employees.
  • External agency quality representative accountabilities: Serves as a Legacy Health liaison to external agency performance improvement initiatives as requested. Represents Legacy Health System in a professional manner and seeks to build positive working relationships with the healthcare community.
  • Culture of Safety promotion:  Supports Legacy’s commitment to a culture of safety by encouraging a safe, blame-free committee environment for team process activities.  Maintains confidentiality.
  • Other duties as assigned by the Manager, Quality Improvement



  • As required by licensure. BSN or Bachelor’s degree in related health care field required; BSN preferred.
  • Certified Professional in Health Care Risk Management (CPHRM) preferred.
  • Formal training in CQI principles and tools and techniques preferred.
  • Certified Professional in Health Care Quality (CPHQ) preferred.
  • Lean or Six Sigma certification preferred.


A minimum of 5 years of experience in healthcare risk management and quality improvement with at least two years in each field.

The quality improvement requirement may include the following: quality committee member, involvement on problem-solving teams, management of data, and use of CQI tools and techniques, including at least one year of experience in the healthcare field.  Demonstrates experience in process improvement with measurable results.



  • Requires knowledge of and remains current in: clinical risk management; healthcare standards of practice; LH policies and procedures; relevant health law doctrine; professional and general liability and liability insurance; and specified regulatory requirements for management of grievances and adverse events.
  • Maintains and demonstrates skills in investigation, witness interviewing techniques, negotiation and conflict resolution.
  • Manages critical situations in a professional, objective and effective manner.
  • Has the ability to make independent, real time decisions within the clinical risk management and patient safety scope of responsibility.


  • Leads using performance excellence and other quality improvement tools and techniques to improve outcomes
  • Ability to provide consultation and support for organizational quality planning that supports Legacy’s strategic pathways and annual goals and objectives.
  • Problem-solving skills, data abstraction and analysis
  • Able to lead, facilitate, and motivate effective teams (small and large)
  • Project management skills
  • Demonstrated knowledge of regulatory standards related to the monitoring of health information and performance improvement


  • Team oriented
  • Ability to handle multiple projects simultaneously
  • Well-developed conflict resolution skills
  • Proficient in computer skills (i.e. Excel, Word, PowerPoint)
  • Proficient with personal computers, network applications, Internet, and risk management and patient relations software
  • Effectively communicates both verbally and in writing
  • Excellent public speaking skills and adult training abilities
  • Is able to engender trust among internal customers
  • Provides excellent customer service for internal and external customers
  • Works independently and establishes and reevaluates priorities on a daily basis
  • Meets deadlines


Follows guidelines set forth in Legacy’s Values in Action

Equal Opportunity Employer/Vet/Disabled


Current Oregon and Washington state RN licensure required.


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