Position Summary:
Provides oversight in the development and implementation of quality improvement and organizational excellence plans, patient safety, accreditation, and regulatory. Directs and coordinates the department's activities, and staff to ensure they are efficient, timely, and meet quality objectives; and that all activities and services are carried out in compliance with local, state, federal, and governmental regulations, and laws. Directs and leads process improvement projects and teams that achieve measurable, sustainable change, promoting service, process, and operational excellence. Directs the overall Risk and Patient Safety program. Coordinates patient safety improvement programs that reduce the risk of injury and promote reporting of incidents.
Essential Functions and Responsibilities:
Ensures MHMG follows and adequately prepares for Regulations, including CMS/MDCH, OSHA and other accreditation requirements.2. Provides leadership and oversight for all patient safety endeavors at the site including:
a. Prevention, Detection and Correction of Patient Safety events
b. Staff education in error reduction
c. Culture of Safety
d. Just Culture
3. Assists in the development and implementation of Patient Safety and Quality Annual Goals and Objectives in line with McLaren Strategic Plan and Board.
4. Responsible for development of the QAPI programs for service lines of home health and hospice.
5. Patient Safety Identification/Event Management
a. Responsible for identifying and aggregating adverse trends and/or patient safety concerns for presentation to CMO and Patient Safety & Quality Committee.
b. Compiles information from staff, managers, unit managers, site administrators and physicians on patient safety concerns and provides recommendations to leadership for next steps.
c. Conducts initial investigation of all potential patient safety events and provides summaries and recommendation to CMO and site administration ongoing.
d. Facilitates the Root Cause Analysis process in conjunction with CMO & CNO.
e. Develops/manages and presents education programs and other educational materials addressing areas of concern on quality and patient safety.
f. Provides risk and patient safety orientation to newly hired management employees.
g. Acts as system resource for disclosure process and learnings.
6. Directs and leads process improvement projects and teams that achieve measurable, sustainable change, promoting service, process, and operational excellence.
7. Provides oversight in the development and implementation of quality improvement and organizational excellence plans in compliance with patient safety, accreditation, and regulatory bodies.
8. Develops programs and services that produce measurable improvements processes improvement and practices that affect patient safety.
9. Serves as a liaison to ensure clinical services are provided in accordance with safety standards established by federal and state regulatory agencies and CHAP accreditation standards.
10. Communicates with and educates leadership and staff regarding quality and patient safety initiatives and activities.
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Required Qualifications:
1. Associate degree in nursing.
2. Current state license as a registered nurse.
3. Certified Professional in Healthcare Risk Management (CPHRM), Certified Professional in Healthcare Quality (CPHQ) or other Patient Safety training/certification desired (CPPS, IHI Executive Development) within 12 months of hire.
4. Two years of healthcare related experience.
Preferred Qualifications:
1. Bachelor’s degree in nursing, public health, or healthcare related field.
2. Four or more years of healthcare experience, preferably in patient safety and/or healthcare risk management.