Job Summary
The Corporate Director of Patient Safety is responsible for advancing the organization's mission by strategically designing, developing, implementing and continuously enhancing the Patient Safety Program, including day-to-day administration of risk management and patient safety activities, coordination of real time responses in relevant situations, risk identification and mitigation, and related initiatives, all with the objective of identifying potential areas of exposure in clinical patient care and proactively recommending and implementing strategies to attain optimal clinical outcomes while minimizing risk to patients, physicians and the hospital. Works to develop goals and objectives in alignment with Administration, Legal, Quality, Compliance, Medical Staff, Security, Education, Finance, Employee Health, and staff at all levels of the organization.
Responsibilities
• Designs, implements, and evaluates work of patient safety in the organization including: development of safety culture, expansion of team activities at the department and organizational levels, and directing the process improvement process for adverse events.
• Assesses organizational risk through analysis of safety reporting including intervention in adverse events.
• Works with appropriate others to ensure a comprehensive hospital-wide mechanism of incident reporting system which includes investigation and follow-up on actions taken. Formulates preventive strategies and evaluates effectiveness.
• Assists managers and/or service line administrators in designing risk management programs within their own departments and services.
• Lends expertise to: the identification of general areas of potential risk in the clinical aspects of patient care and safety; the development of criteria for identifying specific cases with potential risk, and evaluation of these cases, the correction of problems in the clinical aspects of patient care and safety identified by risk management activities; and the design of programs to reduce risk.
• Assures necessary information is communicated among departments/services and/or professional disciplines when problems or opportunities to improve processes involve more than one department/service and/or professional discipline.
• Designs and participates in facility-wide in-service and orientation programs in cooperation with Organization Development and Training for medical, resident and hospital personnel. Educates all levels of staff so that patient safety, risk awareness, problem reporting and risk prevention strategies are accomplished.
• Coordinates activities with Insurance Manager for follow-up on recommendations of on-site regulatory, insurance and risk management surveys.
• Assures collection, analysis, maintenance and distribution of risk management information including trends in incidents and claims experience data.
• Provides analytic summary reports to appropriate Executive Staff, to Board of Trustees Committee on Quality and to departments/service lines at least quarterly.
• Responsible for annual evaluation of the effectiveness of the Risk Management Program and making recommendations for improvement.
• Provides reports of analysis with recommendations for improvement to administration and appropriate committees.
• Deploys and improves an effective system of response and follow up to adverse events: Sentinel event team structure Training for event investigation. Develops and participates in disclosure process including administration and physicians. Defines RCA process and assures effective interventions which are deployed across the organization. Interacts with Legal Council for cooperation in recognition, investigation, and maintenance of accurate records for adverse events.
• Supports the use of Just Culture within the scope of patient safety.
• Integrates patient safety in QIPS and on boarding of physicians.
• Supervises the Patient Safety Coordinator and Staff Assistant.
• Expands knowledge and skill in areas of Safety as assigned by Safety Officer.
• Lead/directs teams to achieve breakthrough results.
Knowledge, Skills & Abilities
Patient Group Knowledge (Only applies to positions with direct patient contact)
The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.
Competency Statement
Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.
Common Duties and Responsibilities
(Essential duties common to all positions)
1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.
Education
• Master's Degree (Required) Experience: 2 years management experience 5-7 years clinical experience Substitution: May substitute BSN with master's degree in management, healthcare administration, or related field for the master's degree in nursing
Credentials
• No Certification, Competency or License Required
Work Schedule: Days
Status: Full Time Regular 1.0
Location: General Hospital
Location of Job: US:WV:Charleston
Talent Acquisition Specialist: Anita J. Ferguson anita.ferguson@vandaliahealth.org