Job Description

General Purpose of Job:

The Director of Patient Safety has primary oversight of the system-wide patient safety program. This leadership role directs staff within the organization toward process improvements that support the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes. This individual will also provide leadership to professionals/caregivers within the Patient Safety Department. The Director of Patient Safety serves as an educator on the system-based causes for medical error, consults with management and staff, and communicates literature-based ideas regarding effective patient safety strategies to others within the organization.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Team member may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Initiates and oversees the development of a comprehensive patient safety program that includes the analysis and trending of data related to hospital initiatives.
• Works closely with the Quality, Risk Management, Care Management, Infection Prevention, ambulatory, Nursing and Medical staff to ensure a safe environment for our patients and staff.
• Collaborates with the Quality Department as well as with the Chief Medical Officer to ensure that organizational wide safety initiatives are rolled out effectively and risk reduction strategies implemented wherever appropriate while engaging stakeholders in the process.
• Proactively communicates with and educates leadership and staff regarding patient safety initiatives and activities.
• Provides input and direction to staff responsible for the accurate and timely submission of all regulatory safety data reporting requirements including but not limited to: Leapfrog, Patient Safety Organization (PSO), etc.
• Acts as a consultant for UMH regional staff and physicians on issues related to patient safety and subsequent performance improvements to achieve effective and efficient operations and excellent patient outcomes.
• Provides quarterly reports to designated committees, administration, and the Board of Directors involving the Patient Safety Program and other key patient safety initiatives.
• Chairs the Patient Safety Committee and actively participates in other committees promoting patient safety and involved activities.
• Performs other duties as assigned. These may include but are not limited to: Maintaining a current knowledge base of use standards of care in professional practice, pursuing self-directed learning, and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.
• Work with the Regional Associate Chief Quality Officer in the stategic development and direction of the integrated, network-wide quality/patient safety improvement plan.
• Evaluates performance through the development/maintenance of statistical processes, control charts and databases.
• Establish timelines and priorities for projects; coordinate action plans; and monitor results that are consistent with the overall strategic goals and imperatives.
• Direct efforts to identify opportunities for optimization, standardization, and continuous quality improvement based on evidence-based practices, regulatory and accrediting agency requirements as well as monitoring high risk, high volume and/or problem prone processes.
• Ensure compliance with regulatory and accreditation standards for patient safety.
• Assess the organization's current patient safety culture and implementing creative strategies to heighten this culture.
• Serve on, facilitate and/or oversee hospital and network committees related to patient safety, medication safety.
• Assist with administrative responsibilities for the Patient Safety department including annual budget preparation, conducting performance reviews, hiring process and record keeping.
• Assist with a continued state of readiness related to Joint Commission and HFAP accreditation.

Job Requirements

General Requirements	* Demonstrates knowledge and maintains and respects patient right to privacy by following the HIPAA Privacy and Security policies and procedures. * Adheres to BASE values and standards of behavior (Belonging, Access, Safety, Experience). * Role model behaviors that value the diversity of our caregivers, patients and customers and supports creating an environment that is inclusive, welcoming and respectful. * Adheres to established best practices (i.e. Rounding, Thank You Notes, AIDET, etc.). * Establishes organizational priorities, beliefs, attitudes, and values towards safety by regularly communicating on safety matters and evaluating leaders' effectiveness in establishing a safe environment. * Demonstrates commitment to safety by establishing an environment in which safety issues are promptly reported and appropriate actions are taken. * Adheres to policies and procedures designed to avoid, prevent and reduce the spread of communicable diseases.
Work Experience	* Minimum 5 years of progressive administrative leadership experience in patient safety activities in an academic medical center or large, integrated, tertiary health care setting providing expert level understanding of the art and the science of patient safety. * Demonstrated experience in utilizing data for continuous quality improvement, the IHI Model for Improvement, and common statistical, spreadsheet and database management programs.
Education	* Bachelor's Degree in health related field. * Healthcare professions requiring licensure in the State of Michigan, must have and maintain current licensure.
Specialized Knowledge and Skills	* Strong interpersonal, facilitation, and team building skills, with proven ability to influence across functional line. * Persuasive oral and written skills, as demonstrated in oral presentations and written reports required. * Flexible/adaptable with the ability to work with diverse groups of people and in many different situations.