Director Patient Safety & Clinical Risk

Position Summary

Provides administrative leadership, direction and supervision of the MHC

Quality Improvement and Patient Safety Program for assigned subsidiary(ies). Responsible to

foster a safety culture with leaders, providers and staff that promotes a just culture and reduces

preventable harm. Develops and presents education programs based on error prevention

strategies aligned with safety reporting data and learnings from root cause analysis. Responsible

for the oversight of the safety risk occurrence portal, trending and monitoring safety events for

individual or aggregate analysis.

Essential Functions and Responsibilities :

1. Provides leadership and oversight for patient safety activities, including :

a. Prevention, detection and mitigation of safety events

b. Review, classification, and management of reported safety events

c. Causal analysis

d. Education programs

e. Culture of Safety Survey

f. Just Culture

g. Daily Safety Huddles, as applicable

h. Safety Event Review Team

2. Responsible for ensuring reported safety events are vetted and managed according to

severity level, utilizing standard safety event classification and event management

strategies, including but not limited to root cause analysis. Components of causal analysis

include assessing for contributing factors related to staffing, healthcare equity / disparities,

and system weaknesses.

3. Responsible to lead safety event investigations specific to potential serious, sentinel, or

never events. Ensures a timely response to adverse events that will eliminate further risk

for harm (e.g., sequester equipment). Ensures preservation of surveillance video that may

help identify contributing factors to the safety event.

4. Escalates potential serious, sentinel, and never events to subsidiary and system leaders

using standard communication pathways (including safety event review team) to foster a

mutual response to the event.

5. Represents department at committees, board meetings, etc. to outline subsidiary safety

data, safety event trends, proactive activities (safety champion program), causal analysis

and / or disclosure activities while maintaining integrity of the information in a

confidential, peer protected manner.

6. Continuously monitors and trends reporting data for subsidiary analysis and / or systemwide improvements.

7. Develops and implements education programs that will provide safety skills and

strategies to staff, leaders and providers.

8. Responsible for analyzing subsidiary culture of safety survey responses, utilizing

responses to inform and develop process improvements at the department and subsidiary

level, guided by system leadership.

9. Represents subsidiary(ies) as Patient Safety Officer to ensure clinical services are

provided in accordance with safety standards established by federal and state regulatory

agencies.

10. Responds to regulatory visits as requested by subsidiary leaders, requests regulatory

reports through system pathways to maintain integrity of information shared with

regulatory bodies.

11. Supervises, evaluates, motivates, delegates, advises staff, and provides opportunities for

professional and technical growth.

12. Performs other duties as assigned.

Qualifications : Required :

• Bachelor’s degree in clinical or healthcare focus
• Three years of healthcare experience
• Certified Professional in Patient Safety (CPPS), Certified Professional in Healthcare

Risk Management (CPHRM), Certified Professional in Healthcare Quality (CPHQ) or

other patient safety certification. If not currently certified, must be within 2 years

from date of hire.

Preferred :

management.