Job Purpose & Position Overview

The purpose of this position is to support the administration of Winnebago Comprehensive Healthcare System (WCHS) and its divisions with the provision of a safe and secure environment for the care of patients, visitors, providers and members of the workforce. The Safety Officer is responsible for executing and managing the Safety program for WCHS, and will serve as the designated Safety Officer. This is a role in which the person serves regularly in a highly visible capacity. Advanced experience, proven skills, professional demeanor, and ability to handle difficult and sometimes stressful circumstances are a clear expectation. The position will be responsible for implementing and maintaining various aspects of the Environment of Care (EC) Program, which includes safety and security management, fire safety, hazardous materials and waste management, medical equipment, utilities management, emergency management, and environmental stewardship. The position will collaborate with the Compliance & Risk Manager to investigate causes of adverse incidents and provide valuable data and information up through the Quality Management systems to improve experiences and outcomes for our patients and employees.

Specific Job Duties/Responsibilities:

• Manages and maintains EC and Life Safety compliance in accordance with regulations from a number of regulatory agencies, including the Center for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), the National Fire Protection Association (NFPA), and identified industry best management practices.
• Coordinates implementation of Environment of Care, Safety, Security, Emergency Preparedness, Medical Equipment, Hazardous Materials and Waste Management, Life Safety, and Utilities management plans as they directly relate to the health care setting and the overall environment of care.
• Participates in committee activities associated with risk management, safety, and infection control. Acts as chairperson as appropriate.
• Identifies risks based on regulatory interpretation and other methods, and applies to policy creation.
• Coordinates regular safety assessments and audits to uncover vulnerabilities, regulatory or accreditory violations, and opportunities for improvement in existing WCHS facilities and programs; facilitates corrective action or recommends solutions to applicable management as appropriate.
• Provides oversight of EC in efforts to maintain high standards of safety, regulatory compliance, maintaining documentation of findings and improvements.
• Participates in incident investigation to identify causal factors to determine how incidents might be prevented in the future.
• Monitors potential and actual environmental hazards.
• Participates in root and apparent cause analysis and recommends remedial and corrective action.
• Works in coordination with appropriate staff to ensure life safety and or infection control risk assessments are completed for repair or construction projects.
• Works in coordination with the Infection Control Officer and Infection Control Committee to ensure full compliance with infection prevention principles and practices.
• Serves as the designated Safety Officer for WCHS.
• Develops, implements and manages WCHS workplace safety program and initiatives and provides continuous assessment and improvements.
• Collaborates with the Human Resources and Employee Health Nurse on all worker’s compensation cases. Specific duties include investigation of incident(s), record and track data, and implement recommended workplace modifications to resolve and reduce work-related injuries, instances of lost-time and work compensation claims.
• Reviews safety hazards, and construction / repair projects to determine if Interim Life Safety Measures are required to maintain life safety compliance.
• Conducts quarterly fire evacuation drills as required by regulatory guidance.
• Tracks hazards and abatements to completion using Corrective Action Plans (CAP) and abatement lists.
• Serves as member of the Hospital Incident Management Team (HIMT) during disaster or emergency operations.
• Interacts with external agencies as a primary point of contact during regulatory surveys.
• Assists in orientating new employees and departmental staff members as needed.
• Fills in for Compliance & Risk Manager on specific duties as assigned.
• Attends all assigned meetings and prepares reports as requested.
• Demonstrates work practices consistent with WCHS and department-specific safety, security and infection control policies.
• Maintains and continuously improves all Environment of Care management plans, ensuring compliance with regulatory standards and implementation at the hospital.
• Maintains regulatory readiness documentation, ensuring WCHS is in compliance with regulatory standards and that the personnel are trained and ready for regulatory inspections
• Promotes organizational use of WCHS’s electronic incident reporting system and coordinates incident review and follow-up within areas of accountability.
• Maintains the emergency recall system for hospital staff and ensures data is updated regularly.
• Maintains WCHS scorecard that documents and tracks all safety data, and analyzes data and assigns and tracks performance improvement actions

• Develops, implements, and delivers safety education programs and materials to train staff to detect, mitigate, and avoid workplace hazards.
• Provides technical guidance to management, surveyors, and other appropriate parties regarding occupational health and safety-related problems regarding accreditation standards.
• Develops and implements educational programs for EC regulatory readiness.
• Provides policy and procedure interpretation and education as it applies to the Environment of Care, Life Safety, and Emergency Management Plans
• Conducts research on applicable regulations/standards concerning workplace safety, and integrate findings into policies and procedures to ensure regulatory compliance
• Provides education and training regarding accreditation standards and regulations as they relate to WCHS policies and procedures

Required Qualifications/Skills:

• Bachelor’s Degree or other acceptable combination of education and Safety Management experience preferred.
• Three years of experience in safety management, risk management, emergency management, compliance, quality improvement, or infection control required.
• Three (3) years of supervisory experience required
• Previous experience in a health care facility strongly preferred
• Previous experience developing policies and procedures required
• Knowledge of hospital/facilities management, clinical engineering, and/or regulatory standards.

• Knowledge of NFPA, TJC, CMS, and OSHA regulatory codes.
• Knowledge of Microsoft Office and Computerized Management System (CMMS) database applications.
• Analytical skills to comprehend and interpret complex regulations, perform data analysis, and communicate results to others.
• Strong interpersonal and conflict management skills.
• Organizational and project management skills.

• Effective written, verbal, and presentational communication skills.
• Individual may be required to participate in job related training in relation to hospital accreditation, safety, emergency management, and life safety as directed by hospital executive management.

Physical Requirements:

• Normal to heavy office work which includes the ability to lift up to 50 lbs.
• Regular work in construction and industrial areas performing inspections for safety hazards, and limited exposure to construction hazards.
• Required to perform walking tours of the hospital facility and campus, to include climbing, and lifting.
• Regularly required to walk, stand, and sit for extended periods of time and use hands to operate computer keyboard, phone, and various office equipment.
• While performing daily duties, the employee is regularly required to talk and hear.

Cognitive Requirements:

• Reading, writing, calculating
• Above average social interaction skills
• Reasoning/Analysis
• Works with minimal to no supervision

Language Requirements:

• Must possess the ability to read, write, and speak the English language fluently.
• Must be able to continually and effectively employ professional verbal and written communications skills.

Certificates, Licenses & registrations:

• FEMA ICS 100/200/300/400/700 preferred
• Relevant certifications in areas of Environmental/Regulatory compliance and safety required.
• All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check.

WCHS is an equal opportunity employer. Employment practices are free of discrimination. As provided by Federal Law, all qualified Native American applicants shall receive preference over Non-Native American applicants. In the absence of qualified Native American applicants, consideration will be given to all other applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, marital status, veteran status, genetic information, disability or any other reason prohibited by law in provision of employment opportunities and benefits.