Job Summary

Responsible for the coordination and oversight of the patient safety system. Coordinates and facilitates patient safety activities and teams, consults and educates teams and staff on patient safety, human factors, culture of safety, and error education tools and methodologies. Advises teams on appropriate data collection methodologies. Establishes, maintains, and monitors appropriate patient safety databases and reports. Conducts and monitors results from Root Cause Analysis (RCA), Failure Mode Effect Analysis (FMEA), Pro-Active Risk Assessments (PRA), and other patient safety initiatives. Researches appropriate literature for benchmarking, and facilitate patient safety teams, committees, and reports for leadership. Oversees conduction of medical chart reviews for data collection and timeline reporting.

 

Responsibilities

• Establishes a culture of patient safety and risk awareness. Works to ensure a comprehensive, hospital-wide mechanism of incident reporting system which includes investigation and follow-up actions taken. Formulates preventatives strategies and evaluates effectiveness. Performs safety review of adverse events to ensure accuracy, establishment of priority and follow-up as appropriate. Escalate events as needed. Assists in designing, implementation, and evaluation of the patient safety system. • Recommends and assists in the implementation of processes that will lead to improved care delivery by reducing errors and continuously improving patient safety and quality. Serves as expert in RCA, PRA, FMEA, and other safety event initiatives. Conducts assessments, leads team and prepares teaching materials for support of the patient safety system. Facilitates teams to ensure appropriate identification, correction, evaluation, causation and preventative strategies for safety events. Mobilizes appropriate resources for timely and effective team activities around serious or never events. Monitors action plans and intervenes to ensure actions have reduced or eliminated the hazard, process improvements made. Participates in organization training and development programs to enhance the patient safety system. Participates in quality initiatives and improvement activities as needed. Develop and evaluate policies as needed. • Serves as an on-call responder to patient safety events. Coordinates Safety Culture Assessment with implementation, monitoring and evaluation of action desired action plans. Participate in preparing reports to Patient Safety, Administration, managers and others as identified. Edits data utilizing appropriate software packages. Recognize deficiencies in statistical data and take steps to validate and correct. Develop statistical analytical standards for data output to ensure high degree of accuracy. Delivers reports to meetings and committees when needed. Participates in data collection, analysis, and medical record review related to performance improvement and patient safety activities. Provides consultation and in-services to hospital departments, services and committees about performance improvement and patient safety topics and standards. Completes safety reports, including analysis of data, identification of trends, and makes recommendations for improvements. • Supports use of DMAIC model and use of Lean/TPS tools to achieve strategic goals focusing on optimizing workflow and design. Facilitates use of DMAIC process and PI template at the department level with reporting of outcomes to Patient Safety Committee and other teams as appropriate. Seek reliable sources and maintain currency and availability of information related to patient event statistics, comparative databases, specialty medical organization standards and guidelines for benchmarking. Participate in annual evaluation of the effectiveness of patient safety and risk management programs by maintaining and providing overview and summary documents and year to year comparisons of studies and projects undertaken including trending of results. Participates in literature review activities and best practices related to patients safety and shares information for enhancement of the patient safety system. Attends and participates in committees as the patient safety representative as assigned. • Perform work in accordance with all departmental pay practices and scheduling policies, perform work in alignment with the overall mission and strategic plan of the organization; and follow organizational and departmental policies and procedures, as applicable. Other Duties as assigned.

 

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 (in healthcare field preferred)Experience: 5-7 years in healthcare management Substitution: May substitute a Bachelor's degree and 5 additional years of experience in Nursing, Safety or Management

Credentials 

• Registered Nurse (Required)

 

Work Schedule: Days

Status:  Full Time Regular 1.0

Location: General Hospital

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren.Lane@vandaliahealth.org