Manager Quality/Patient Safety & Risk Regulatory

Position Summary: 

This position oversees a comprehensive, Quality, Regulatory, Patient Safety & Risk system wide patient safety and risk mitigation program. In doing so, the Patient Safety Risk Mitigation develops, implements, and evaluates the patient safety and risk mitigation program for the HPH. The Patient Safety and Risk Mitigation Director will supervise the investigation of errors and plans for resolution of all safety related incidents, including those involving visitors, patients, and situations posing a threat. Responsible for assessment, development, implementation, and evaluation of clinical outcomes and processes supporting patient care, under the supervision of and direct reporting to the Vice President of Quality, and in collaboration with the clinical team and Medical Staff

Essential Duties and Responsibilities:

• Develop and implement best practices in patient safety and risk mitigation initiatives practices driving a proactive approach and prevention of patient harm.
• Conducts investigation of errors and then plans for resolution of all safety related incidents, including those involving employees, patients, and situations posing a threat to the health care setting and equipment.
• Aid in facilitating implementation of organization-wide monitoring and evaluation activities, as well as applying the tools and techniques of continuous performance improvement and patient centered strategies and goals.
• Maintains records of patient-related errors and evaluates this information to identify the cause of the error.
• Collects, reviews, and analyzes information from the facility's safety programs to identify corrective action and programs as necessary.
• Recommends changes, policies, or programs that could prevent future errors.
• Responsible for policy and procedure committee.
• Designs and presents training programs meant to increase awareness of patient safety initiatives/Quality improvement/Regulatory topics
• Ensures compliance with state and federal regulatory requirements by reviewing and submitting data to various agencies not limited to CMS, TJC, NHSN, CDC, Leapfrog, etc.,
• Reviews and analyzes facility occurrence reports to identify clinical risk issues.
• Conducts analysis not limited to Root cause analysis, Apparent cause analysis, Incident analysis, and Health care failure mode and effect analysis
• Performs regulatory survey planning as needed and performs regulatory tasks
• Analyzes data both for patient safety & Risk, Quality and Regulatory
• Manages Quality assessment and performance improvement and working with unit leaders on ongoing Quality improvement using Plan Do Study and Act model
• Identifies trends necessitating intervention and works with Directors in planning and implementing actions to address identified issues
• Participates and assists with Infection prevention related events

Qualifications:

• A Bachelor’s, Masters or Doctoral degree in a healthcare profession, health administration, or public administration, or a law degree.
• This position requires a minimum of 2-5 years of experience in acute hospitals and/or integrated healthcare delivery systems, and a broad knowledge of hospital operations.
• Clinical experience required, bachelor’s degree, master’s degree preferred,
• Certifications: CPPS, or CPHQ or CPHRM designation is preferred or obtain within 2 years of hiring
• Demonstrable experience with relations required.
• Ability to work independently and maintain accountability for work.
• Must have excellent computer skills to include word processing and spreadsheets.
• Ability to provide leadership and direction within his/her duties.
• Must be able to maintain acceptable attendance and adhere to scheduled work hours.