Responsible for supporting day to day continuous patient safety improvement for assigned Ministry(s), Medical Group practices, and/or business units. Works collaboratively with leaders, clinicians and other staff in the development and implementation of strategies to identify and reduce risks, improve safety and meet regulatory requirements. Ensures implementation of an integrated patient safety program to position organization as a national leader in patient safety.
Job Responsibilities and Requirements:
Facilitates patient safety efforts and coaches others in the development of patient safety improvement capabilities with emphasis on process redesign and measurement. Provides direction, in conjunction with continuous improvement (CI), to the department and business unit leadership in the planning of a systematic, organization-wide approach to continuous patient safety improvement.
Manages the event reporting process. Works with departments to mitigate the immediate risks to patients as a result of human or systems errors through various cause analysis approaches. Works with Risk Management to evaluate trends with identification of systems opportunities that lead to patient harm, in addition to leading efforts for systems improvement to prevent such harms. Provides input, guidance and directions, as appropriate, in the management of such events. Provides a regular cadence of outcomes reporting to Clinical Programs, ministry leadership, and/or other designated groups as requested.
Supports improvement efforts by facilitating cause analysis teams. Works with departments to assist with changes in processes, policies, and workflows based on cause analysis findings. Monitors progress of changes at regular intervals to ensure effectiveness and sustainment of interventions.
Participates in/leads entity, regional, and system patient safety committees, Sentinel Event/Serious Safety Event meetings, teams, work groups, and huddles. Serves as a patient safety consultant to various other committees to ensure integration of patient safety work across the continuum of care.
Analyzes trends of performance metrics, identifies opportunities for improvement, develops and maintains Management Action Plans (MAPs), measures success of the MAPs, and creates the follow-up metrics for each activity to maximize success. Assists with the coordination of the annual analysis and implementation of the SSM Patient Safety Plan. Assists leadership in defining key performance indicators and defining measurement tools to evaluate quality improvements in patient safety.
Serves as a resource in conjunction with management regarding applicable Joint Commission standards as they relate to patient safety requirements and other compliance regulations. Facilitates the development of strategies to remain compliant with all regulatory requirements and assists with developing and revising policies and procedures as needed.
Rounds routinely in all clinical care departments to assess and address risk reduction and patient safety activities/concerns. Follows up with department managers and leadership regarding patient safety concerns as noted during rounding to ensure risk mitigation.
Plans, prepares, and coordinates presentations and educational opportunities for new employees and providers regarding patient safety strategies. Facilitates and supports implementation of patient safety program and just culture initiatives and assists with coordination of education for staff and clinicians as needed.
Demonstrates mastery of facilitation skills (team and individual), data analysis, and statistical process control to effect improvement in corporate quality goals and clinical outcomes. Coordinates the FMEA (Failure Mode Effects Analysis) process and other patient safety tools such as patient risk assessments, as appropriate.
Facilitates compliance with The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS) and state quality and patient safety requirements by coordinating, organizing and communicating appropriate information to designated committees, teams, work groups and leadership in a timely fashion. Leads initiatives for high priority opportunities as identified by leadership.
Performs other duties as assigned.
Three years' clinical experience
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
Frequent keyboard use/data entry.
Occasional bending, stooping, kneeling, squatting, twisting and gripping.
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
Licenses / Certifications:
FUTURE - Certified Professional Healthcare Quality (CPHQ) within 24 months - National Association for Healthcare Quality (NAHQ), FUTURE - Certified Professional Patient Safety (CPPS) within 24 months - Institute for Healthcare Improvement (IHI)
Day Shift (United States of America)
85740130 Patient Safety/Quality
Scheduled Weekly Hours:
SSM Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.