Safety & EM Officer

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

2/1/2024

Entity:

Wisconsin

Job Code:

410006

Job Title:

Safety & EM Officer

FLSA Exemption Status:

Exempt

Management Level:

Individual Contributor

JOB SUMMARY

The Safety & Emergency Management Officer is responsible for achieving optimum health and safety compliance and performance at UW Health facilities in a professional manner by being a content expert and technical advisor on safety and emergency management issues.  Incumbent will be accountable for developing and stewarding safety and emergency management and providing leadership and direction to UW Health staff.  Incumbent is responsible for developing, coordinating and implementing the Environment of Care, Life Safety and Emergency Management Programs within the UW Health system. 

This role is a leadership position within Safety and Emergency Management. Incumbent will direct the planning, development and execution of Environment of Care management plans, policies, training exercises, and outreach programs for a large healthcare organization.  Incumbent utilizes in-depth knowledge of public health aspects of bioterrorism, communicable disease, food-bourne illnesses, environmental health emergencies, mass casualty incidents and mass fatalities to be an effective leader during all phases of emergency management.  Incumbent must stay up-to-date with federal and state recommendations for Emergency Management.

Incumbent will maintain the safest possible physical environment for patients, staff, visitors, and students by organizing and conducting drills, inspections and training required by federal, state, and local authorities having jurisdiction throughout the facilities. The incumbent is responsible for documentation of these activities and follow-up on any concerns or safety issues encountered. In addition, the incumbent assists in the maintaining the records required by all authorities having jurisdiction as well as ensures UW Health compliance with all emergency management, life safety, and environment of care standards of The Joint Commission (TJC) and equivalent Center for Medicare and Medicaid (CMS) conditions of participation. 

Incumbent is responsible for the regulatory compliance, accreditation, and continuous survey readiness at all hospitals, ambulatory sites, surgery centers and business sites related to Environment of Care, Emergency Management and Life Safety chapters. This position is responsible for establishing and maintaining necessary compliance mechanisms, training, inspections, documentation and activities, in conjunction with UW Health Environment of Care Safety Program objectives. The incumbent is responsible for supporting facility specific management and department managers on safety and emergency management issues as well as the institution's compliance with federal, state and local laws and TJC standards.  Incumbent makes timely report of any safety incidents or events.

The Safety & Emergency Management Officer will serve as the Manager of Safety and Emergency Management in his/her absence and may perform other duties as assigned.  The incumbent will represent designated facilities at the UW Health Environment of Care Safety Committee and serves as Chair of various committees as assigned.

The incumbent must maintain confidentiality with regard to access, knowledge of, and participation in employee/employer relations issues.

ESSENTIAL DUTIES

•

Participates independently and in collaboration with corporate/health system wide activities regarding regulatory compliance, policy and performance improvement. They work collaboratively with the Corporate, Administrative, Clinical and Medical Staff leadership, Compliance Officer, Patient Safety Officer, key stakeholders, and other hospital leadership.

•

Collaborates with Safety, Employee Health, and Infection Control departments on program revisions and updates.

•

Creates organization-wide communications related to ongoing training and program processes as needed.

•

Assist with administering and maintaining documentation for the Respiratory Protection Program and the Special Pathogens Program.

•

Administers and maintains all Environment of Care programs in accordance with standards and criteria established by TJC, State, Local, and Federal agencies to ensure compliance to those external requirements.

•

Conducts rounds on a periodic basis to assess emergency preparedness, detect code violations, hazards and inappropriate work processes and procedures. Reviews event reports and investigations and makes recommendations to maintain a hazard free environment.

•

Maintains and oversee all grounds and equipment pertaining to the environment of care.

•

Assesses and conducts risk assessments that proactively evaluate the impact of buildings, grounds, equipment, occupants, and internal physical systems on patient and public safety. Makes effective recommendations for action and correction.

•

Conducts investigations of incidents of property damage, occupational illness, and patient, personnel, or visitor injury relative to unsafe conditions in the environment of care. Make effective recommendations for action and correction.

•

Maintains, coordinates and tests plans, policies and procedures related to emergency response and business continuity to ensure emergency preparedness.

•

Monitors incidents in which a medical device is connected to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990.

•

Facilitates debriefings and completes After Action Reports for real events to identify strengths and opportunities for improvement to emergency response.

•

Coordinates, implements and organizes all aspects of emergency preparedness drills, tabletop, functional and full-scale exercises and After Action Reports for UW Health.

•

Manages, tracks and approves expenses for disaster response, grant funding, and the Safety and Emergency Management budget.

•

Maintains databases and information necessary for compliance with TJC and CMS.

•

Provides training, support and assists department leaders with software for safety and emergency response.

•

Oversees and manages related grant activities and reporting.

•

Analyzes identified environment of care management issues and develops or approves recommendations for resolving them and works with appropriate staff to implement recommendations and monitor effectiveness.

•

Manages complex projects by working with multi-disciplinary teams at all levels of the organization and within external partners.

•

Works directly with the directors and managers responsible for the seven environment of care management plans on investigations, risk assessments and safety issues, as needed.

•

Oversees the development, revision, implementation and evaluation of organization wide plans, procedures, and policies.

•

Creates and revises safety and emergency management policies for the organization; advises on departmental policies to keep them congruent with corporate policies.

•

Directs an ongoing, organization-wide process to collect information concerning deficiencies and opportunities for improvement in environment of care management programs.

•

Collects and analyzes data to follow the institution’s approach to improve organizational performance.

•

Provides direction to Safety Specialists to assist with safety programs.

•

Chairs facility specific Environment of Care Committees and workgroups.

•

Promotes quality improvement, patient and staff safety, and cultural diversity through department operations and by personal performance.

•

Safety and Infection Control Training for Contractors: Provides up-to-date information for contractor training.

•

New Employee Orientation and departmental training assistance for safety matters, as directed.

•

Facilitates staff training and education sessions directed at safety practices and policies as well as educate departments on corporate Safety performance, documentation, orientation, and continuing education expectations.

•

Provides guidance and direction on emergency preparedness training, exercises, drills and community involved programs.

•

Coordinates planning and response to emergencies with UW Health departments.

•

General Training: Provide training materials, classes, and updates for necessary departmental training including OSHA, Decontamination, Joint Commission, Incident Command Center, Emergency Management and other new requirements as directed or as necessary due to risk assessment.

•

Works with clinical departments across the organization to develop and implement necessary training.

•

Environment of Care Rounds: Organize, schedule, and conduct rounds ensuring all locations are surveyed. Conduct and/or participate in periodic CMS and Joint Commission compliance surveys.

•

Local Fire Department, Insurance Company Inspections: Participate in whole building inspections. Create work orders from list of deficiencies. Follow up on work order completion and communicate back on progress and completion of work.

•

Investigate Concerns and Safety Issues: Respond to callers or emails. Provide documentation as necessary. Seek assistance as necessary in solving problems.

•

Maintain updated TJC Survey Readiness electronic resource.

•

Maintain databases and information necessary for compliance with TJC and CMS.

•

Position requires participation with on-call rotation for emergency situations.

•

Participates as a member of the South Central Wisconsin Healthcare Emergency Readiness Coalition and other local emergency operations centers and emergency preparedness committees.

•

Liaises with local, regional, state and federal partners.

•

Represent Safety and Emergency Management Department at various internal and external committees and meetings.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

Bachelor's Degree

in Safety, Nursing, Engineering, Emergency Management, Business or related field

Required

Four (4) years of combined education (Associate’s degree) and work experience may be considered in lieu of Bachelor’s degree, in addition to experience listed below

Master's Degree

in related field

Preferred

3 years

relevant experience, including one (1) year of progressively responsible experience within safety, including leadership and program management.

Required

Experience within an academic medical center or healthcare

Preferred

Experience in respiratory protection, including knowledge of OSHA Respiratory Protection Standards

Preferred

Experience with preparations and planning for emerging or special pathogens (biological threats)

Preferred

Experience in creating, facilitating, and conducting training

Preferred

Experience in CBRNE (Chemical, Biological, Radiological, Nuclear, Explosive) decontamination procedures

Preferred

NIMS IS-100, 200, 700

Required

CSP, CHSP, CHFM, CEM, CHEC or other related certifications related to safety and emergency management

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

•

Knowledge of safety, occupational health and fire protection principals, practices, procedures, codes, standards and regulations applicable to the performance of the full range of complex safety, occupational health and fire protection management responsibilities at the Medical Center.

•

Knowledge of Joint Commission chapters: Life Safety, Environment of Care and Emergency Management desired.

•

Professional knowledge of Emergency Management concepts and principles.

•

Hazardous materials experience and training, such as Healthcare Emergency Response Training (HERT) or similar with decontamination

•

Demonstrated ability to lead, influence and motivate people at all levels of the organization.

•

Knowledge of community disaster response principles

•

In depth knowledge of health care delivery, applicable laws and standards

•

Professional knowledge of NFPA 101 & 99 and OSHA desired.

•

Knowledge of industrial work processes.

•

Professional knowledge of industrial hygiene concepts, principles and practices applicable to occupational health inspections of a large medical center.

•

Knowledge required to recognize environmental factors, stresses associated with complex work operations and to ascertain their effects on the health and well-being of employees.

•

Knowledge of performance improvement and risk management principles.

•

Effective analytical abilities in order to develop and analyze options, recommend solutions and solve complex problems and issues.

•

Effective human relations abilities:

•

Ability to effect collaborative alliances and promote teamwork

•

Ability to ensure a high level of patient, staff, visitor, student and external stakeholder satisfaction.

•

Knowledge to suggest possible approaches to eliminate or reduce environmental concerns.

•

Effective organizational planning, controlling, scheduling and project management abilities.

•

Effective leadership skills

•

Ability to make independent decisions

•

Strong interpersonal and communication skills with experience establishing and maintaining effective working relationship with local jurisdictions, federal and state agencies, local government leadership, governing boards, community representatives and business, hospital/healthcare providers and other community organizations.

•

Effective communication both in written and verbal presentation.

•

Knowledge and ability to use various computer programs and applications.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

☐

Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

☒

Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

☐

Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

☐

Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

☐

Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.