Patient Safety Officer

Bargaining Unit: Non Represented - Professional

Rate of Pay: $64.99/hour + DOE

Summary
In collaboration with the Risk Manager, responsible for the enterprise-wide risk management/patient safety plan with the goal to eliminate or reduce the incidence and severity of harm/loss to patients, families, staff, and the organization. Responsible for the Beta HEART program. Coordinates the Reliability Management Team. As the Health System Patient Safety Officer, emphasis is on achieving highly reliable health care through a commitment to the goal of zero harm; promoting a safety culture, which ensures employees are comfortable reporting errors without fear of retaliation; incorporating highly effective process improvement tools and methodologies into our work flows; and ensuring that everyone is accountable for safety and quality.

• In collaboration with the Risk Manager, responsible for the following:
  • Enterprise-wide risk management/patient safety plan, including annual review and approval
  • Reviews and revises the plan, at least once a year, but more often if necessary, to evaluate and update the plan, and to incorporate advancements in patient safety practices.
  • Develops, implements, and complies with the plan for the purpose of improving the health and safety of patients and reducing preventable patient safety events.
  • Participates in Root-Cause Analysis (RCA)/Event analysis meetings by documenting discussion points and action plans in the event reporting system.
  • Monitors implementation of corrective action plans for RCA/event analysis
  • Makes recommendations to eliminate future patient safety events
  • Conducts Failure Modes and Effects Analysis (FMEA) as new or revised processes are developed.
• In the absence of the Risk Manager, responsible for the event reporting system review, follow up notifications, and event investigations, as needed.
• Promotes a reporting process that supports and encourages a culture of safety and reporting of patient safety events
• Provides ongoing patient safety training for facility personnel and health care practitioners
• Identifies process improvement opportunities and works with key stakeholders to implement action plans
• Coordinates the Reliability Management Team (RMT), including meetings, and ensures follow up on identified patient safety initiatives as outlined in the Risk Management/Patient Safety Plan.
• Develops, monitors and reports activities to improve patient safety, focusing on Critical Access Hospital (CAH) National Patient Safety Goals, Hospital Acquired Condition (HAC)s, Institute for Healthcare Improvement (IHI), and Agency for Healthcare Research and Quality (AHRQ) best practice recommendations.
• Responsible for patient safety standards in the applicable accreditation survey, state licensure regulations, and federal conditions of participation.
• Assists with regulatory compliance, accreditation and state survey process, through staff education and survey preparedness rounds.
• Coordinates survey preparedness rounds, and provides survey rounding recommendations to the Director/Manager, and assists with process improvement, and staff education as needed.
• Serves as a patient safety and High Reliability organization subject matter expert. Functions as process improvement team leader/member to reduce hospital acquired conditions, injuries, errors, and unintended outcomes. This expertise is provided in various venues as appropriate or assigned.
• Identifies and implements patient safety best practice initiatives by reviewing sentinel event alerts, Patient Safety Organization information, and other key organizations and references.
• Coordinates the BETA HEART® (healing, empathy, accountability, resolution and trust) program, which creates a reliable, sustainable, and transparent culture of safety. This includes the annual culture of safety survey. Compiles survey results, conducts debriefings, and assists with identifying plans for improvement with the Director/Manager/Supervisor of each department.
• Coordinates with the Peer Support (Care for the Caregiver) Team which provides Health System employees emotional support and psychological first aid after critical incidents and times of stress.
• Reviews care and treatment provided by staff, and providers, as part of the RCA/event analysis processes.
• Leads process improvement activities, utilizing Lean/Six Sigma principles, with Director/Managers, and Medical Staff, to improve patient safety.
• Recommends appropriate revisions to new or existing policies related to areas of expertise.
• Conducts routine patient safety rounding to identify areas for improvement
• Assists the Quality Analyst, and Director/Manager with maintaining current Performance Excellence boards
• Assists with the event reporting system
• As assigned, works under the direction of the Director of Quality & Regulations to investigate events, conduct research, or other relevant activities associated with the department.
• Prepares and submits summary reports of Patient Safety activities to the Performance Improvement Committee, IVCH Committee, Medical Staff Quality Committee, Board Quality Committee, and Board of Directors, as assigned.
• Represents the department on appropriate committees as assigned.
• Coordinates the quarterly interdisciplinary Patient Safety Committee
• Ensures compliance with Accreditation Commission for Health Care (ACHC), Centers for Medicare & Medicaid Services (CMS), CDPH Title 22, IVCH NRS/NAC standards, and all other federal, state and regulatory agencies.
• Contributes to departmental operations by assuming a range of duties, including those outside the traditional scope of the position, as required to meet organizational needs.
• Maintains a clean and safe working environment.
• Demonstrates System Values in performance and behavior.
• Complies with System policies and procedures.
• Other duties as may be assigned.

Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Supervisory Responsibilities
No supervisory responsibilities.

Minimum Education/Experience
Bachelor's Degree in a health related field and 5 or more years relevant experience

Required Licenses/Certifications
California Registered Nurse (RN) or commensurate clinical license

• Upon hire

• Master’s degree
• Certified Professional in Patient Safety (CPPS) certification
• Green belt or lean certification
• Knowledge of EPIC electronic health record