Patient Safety Manager (Onsite)

Description

Manager, Patient Safety

Welcome to Holy Name, a medical center where innovation is not just a goal — it's a commitment. Here, medical excellence thrives, allowing hope to reign supreme and leaving no room for fear. At our hospital, every patient is cared for with undivided attention — because healing every soul is our sole focus.

Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through graduate medical education, a Pharmacy Residency Program, and our Institute for Simulation Learning. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it this way across generations, every single day, for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine, ensuring nothing is left on the table or the road to recovery.

A Brief Overview

The Safety and Quality Manager is responsible for leading incident investigations, reporting findings, and implementing risk management and quality improvement initiatives. This role involves assessing and addressing patient safety concerns, ensuring compliance with Joint Commission National Patient Safety Goals (JCAHO) and other regulatory standards. The manager collaborates with leadership to develop solutions that enhance care quality, reduce risks, and improve patient outcomes. Additionally, they evaluate hospital systems to identify high-risk areas and implement corrective actions that align with regulatory requirements. In addition to risk management, this role supports staff education, certification, and competency development. The manager maintains and updates policies, ensures compliance with professional standards, and provides training programs to address staff needs. They work closely with interdisciplinary teams to drive process improvements, track corrective action plans, and foster a culture of safety. Through collaboration and a focus on equity in patient care, education, and research, the Safety and Quality Manager helps ensure all individuals receive high-quality, safe, and equitable healthcare services.

What You Will Do

• Monitor, assure, and coordinate Patient safety activities are in compliance with requirements of regulatory, accrediting agencies, and other payer contracts identifying safety expectations. Identify and communicate need for corrective actions as appropriate.
• Administratively responsible for planning, management and implementation of patient safety initiatives across the organization, including TJC National Patient Safety Goals, among others, meeting milestones, deadlines, and deliverables as a patient safety leader, including education and communication plans.
• Work collaboratively with all levels of the organization including senior leadership to produce measurable improvements in patient safety in both process and outcome. Intervenes to prevent non-compliance.
• Maintain, collect, review and analyze PSR/PSI data to ensure appropriate follow-up and recommend changes to policies, procedures or programs to prevent a reoccurrences.
• Performs the investigation of incidents, errors, injuries, patient complaints and organizes follow up
• Responsible for the RCA and Proactive Risk Assessment team process, including but not limited to initiating a team, creating, and communicating to the team, participation of teams, assuring standard reporting, meeting TJC Sentinel Event requirements and deadlines, ensuring team action items are completed, developing status reporting to RCA Subcommittee, and creating status reports for leadership committees.
• Facilitates the Medical/Surgical Peer Review Committee by organizing agenda, data for presentation and the follow up.
• Responsible for working with Risk Management and others to create and ensure a robust process for proactive risk assessments utilizing failure mode effects and analysis (FMEA).
• In collaboration with the Director, responsible for building and implementing safety systems and the promotion of the culture of safety.
• Implement, monitor and evaluate regularly scheduled Culture of Safety Surveys – frequency to be determined with leadership.
• Maintains up to date Regulatory knowledge to foster compliance. Enabling teams across the organization to become experts at guiding their own improvement.
  
  

Education Qualifications

• Bachelor's Degree BSN required
• MSN preferred
  
  

Experience Qualifications

• 10 years 5 to 10 years of Clinical Leadership; required and
• Knowledge of Patient Safety, Performance Improvement, Rapid Cycle Change, Joint Commission Standards, NJDOH Regulation, Legal Affairs, Risk Management required
  
  

Knowledge, Skills, And Abilities

• Patient Safety, Peer Review, Risk assessment of incidents and regulatory knowledge. Skill in collecting and analyzing complex data. Ability to manage various databases.
  
  

Licenses and Certifications

• RN - Registered Nurse - NJ State Licensure and/or Compact State Licensure upon hire
• Certified Professional in Patient Safety (CPPS) Work towards certification in Risk Management ASHRM within 1 Year required
  
  

Holy Name is a mission-driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented team of physicians, nurses, allied health employees, and a wide variety of non-clinical administrative and operational staff members. Holy Name is an Equal Opportunity Employer.