JOB DESCRIPTION
The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.
TITLE: Manager - Patient Safety
JOB OVERVIEW: Responsible for leading and advancing a comprehensive patient safety program across the hospital and affiliated clinic network. This role promotes a culture of safety and drives continuous improvement initiatives to reduce risk and enhance patient outcomes. Provides leadership and oversight to the Patient Safety team within the Quality Department in support of organizational patient safety, quality, and performance improvement goals and initiatives.
DEPARTMENT: Quality Department
WORK HOURS: Typically, Monday - Friday, 7:30 am to 4:00 pm or as needed to meet departmental needs
REPORTS TO: Director Quality & Patient Safety
PREREQUISITES:
Bachelor of Science in Nursing (BSN), required. Master''s degree (MSN, MHA, MPH, or related field) preferred.
Current Registered Nurse (RN) license to practice in WA state, required
Minimum five (5) years of relevant clinical healthcare experience (e.g., patient safety, quality, risk management), to include one year in a leadership capacity (may include lead, supervisor, or program development experience), required.
Experience in hospital and/or ambulatory clinic settings preferred.
Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Quality (CPHQ) preferred.
Knowledge of performance and process improvement (PPI) science, approaches, and methods; PPI project management, culture and process change management.
Knowledge of hospital operations, patient safety regulatory requirements including CMS'' Conditions of Participation, the Joint Commission (JC) accreditation guidelines, WA State WAC''s and RCW''s, PHD and other rules as applicable.
QUALIFICATIONS:
Strong knowledge of patient safety principles and high-reliability organization practices.
Expertise in root cause analysis and performance improvement methodologies.
Experience with TeamSTEPPS or similar teamwork frameworks.
Excellent analytical, problem-solving, and organizational skills.
Strong communication and leadership abilities.
Ability to influence change across multidisciplinary teams.
Experience in establishing and nurturing relationships with departmental teams, providers, leaders, and other customers.
Ability to communicate and effectively present information clearly with all levels of internal and external customers including but not limited to patients and families, providers, clinical personnel, support and technical staff, and external customers and partners.
Ability to write reports, business correspondence, and protocols .
Ability to support staff members and management in maintaining and promoting a positive work environment, cultivating open communication and teamwork with peers, other departments, and management staff.
Ability to support decisions by communicating concerns, questions, and recommendations through appropriate channels.
Ability to maintain confidentiality; with full and complete access to patient medical records, quality assurance and risk management data and information, demonstrate utmost integrity to safeguard patients and the organization.
Ability to utilize a variety of computer applications, including Microsoft Office Suite, RLDatix, Joint Commission, CMS, and DOH applications.
UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT, AND WORKING CONDITIONS:
Works at a computer for extended periods of time. Ability to travel to various departments, including off-site locations, as needed for committee participation, site assessments, educational programs, and consultations. This position may require irregular hours to meet regulatory and internal program goals and deadlines. Available for emergency consultations as needed during off-hours.
PERFORMANCE RESPONSIBILITIES
A. Generic Job Functions: See Generic Job Description for Manager
B. Essential Responsibilities and Competencies:
Patient Safety Program Leadership
Lead and advance the organization''s patient safety strategy, promoting a culture of safety, and embedding high reliability principles across all departments. Partner with clinical and operational leaders to reduce preventable harm, improve system performance, and ensure a proactive, data-driven approach to safety.
Collaborate with clinical and administrative leadership to integrate safety practices into daily operations.
Facilitate continuous daily safety briefings (DSB) across the organization.
Responsible for hiring, timecards, performance evaluations, directing, and developing staff who are members of the patient safety team. This includes orientation, ongoing training, management, and other responsibilities as listed in Criteria for Manager.
Convene meetings with VMC patient safety officers on a regular basis for communication and collaboration, to assure alignment with new regulations and to network internally around shared practice issues (e.g., General safety officer, Medication safety officer, Radiation safety officer, Transfusion safety officer)
Lead and promote High Reliability Organization principles aligned with organizational mission, values, and strategic goals through a collaborative and participatory approach.
Event Reporting & Investigation
Manage incident reporting systems, ensuring timely documentation and follow-up.
Lead safety event reviews, root cause analyses (RCAs) and failure mode and effects analyses (FMEAs).
Ensure that all meeting participants (providers, risk management, leadership, etc.) are briefed on patient safety practices and facilitate proposed action items and follow up.
Prepare appropriate documentation for externally reportable events including Department of Health (DOH) and/or the Joint Commission (JC) incident reports and submit required documentation within regulated timeframes.
Identify trends and recommend system-level improvements to prevent recurrence.
Patient Experience Surveys
Manage all aspects of patient experience survey processes, including vendor coordination, deployment, response tracking, data analysis, and presentation of insights.
Translate survey findings into actionable patient safety and quality improvement initiatives.
Collaborate with clinical and operational leaders to implement changes and monitor outcomes.
Ensure required submission deadlines are met (e.g., CAHPS for CMS)
Performance Improvement
Partner with quality improvement teams to design and implement safety initiatives.
Identify patient safety improvement opportunities through analysis of current practice patterns, statistical data, and evidence-based clinical practices.
Monitor and report key patient safety indicators and metrics.
Use data analytics to drive decision-making and measure outcomes.
Facilitate the Patient and Family Advisory Committee (PFAC).
Partner with patients and families to incorporate their perspectives into safety and quality initiatives.
Serve as co-chair of regular meetings and integrate feedback into organizational improvements.
Workplace Violence Prevention
Serve on the Workplace Violence Prevention Program Committee, providing clinical expertise, guidance, and direction.
Collaborate with Security, HR, and clinical leadership to identify risks and implement mitigation strategies.
Track and analyze incidents and support staff training and response protocols.
TeamSTEPPS Training & Safety Education
Lead sustainment of TeamSTEPPS training across the organization.
Develop and deliver patient safety and teamwork education programs for staff and leadership. Facilitate training in behaviors like preoccupation with failure, deference to expertise, and reluctance to simplify.
Support onboarding and ongoing competencies in safety and communication practices.
Risk Mitigation & Collaboration
Work closely with Risk Management, Quality, Infection Prevention, Operational and Clinical teams.
Identify potential risks and implement proactive mitigation strategies.
Support communication and follow-up processes related to adverse events.
Perform other duties as assigned to meet patient/program needs.
Date Created: 5/26
Revised:
Grade: NC-14
FLSA: E
Cost Center: 8714
Job Qualifications:
PREREQUISITES:
Bachelor of Science in Nursing (BSN), required. Master''s degree (MSN, MHA, MPH, or related field) preferred.
Current Registered Nurse (RN) license to practice in WA state, required
Minimum five (5) years of relevant clinical healthcare experience (e.g., patient safety, quality, risk management), to include one year in a leadership capacity (may include lead, supervisor, or program development experience), required.
Experience in hospital and/or ambulatory clinic settings preferred.
Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Quality (CPHQ) preferred.
Knowledge of performance and process improvement (PPI) science, approaches, and methods; PPI project management, culture and process change management.
Knowledge of hospital operations, patient safety regulatory requirements including CMS'' Conditions of Participation, the Joint Commission (JC) accreditation guidelines, WA State WAC''s and RCW''s, PHD and other rules as applicable.