Director Patient Safety/Regulatory

SUMMARY:

The Director of Patient Safety and Regulatory/Accreditation will play a pivotal role in overseeing and developing comprehensive patient safety initiatives across the organization. This position requires a dedicated professional to advance high reliability and promote a culture of safety through risk mitigation, process development, and adherence to best practices in patient care. The Director of Patient Safety/Regulatory and Accreditation will have a key role in supporting TMCH’s high reliability organization journey and will foster an environment where teams feel comfortable discussing potential errors, near misses, and weaknesses. Reporting to senior leadership, the Director of Patient Safety/Regulatory and Accreditation will work collaboratively to achieve strategic quality and safety goals.

 

ESSENTIAL FUNCTIONS:

· Develops and leads organization-wide best practices through a solid understanding of risk identification/mitigation methodologies and controls with an emphasis on high reliability, process improvement techniques, and industry trends; disseminates consistent, reliable information throughout the organization.

· Promotes the reduction of healthcare errors and improves systems/processes by investigating root causes, working collaboratively with nursing, professional and administrative staff members, focusing on patient safety and developing key strategies to reduce liability exposure.

· Manages the electronic incident reporting system and ensures that events are identified, addressed, trended and analyzed. Process improvement opportunities are identified and facilitated.

· Provides clear short- and long-term direction, leadership, and guidance on patient safety initiatives to staff, management, executives, physicians, customers, and other related stakeholders; provides leadership and direction to functionally related teams.

· Oversees, facilitates and assists with event review sessions such as root cause analysis (RCA), apparent cause analysis (ACA), hot washes, and debriefs to thoroughly investigate sentinel, adverse, or near miss events across the organization.

· Develops and directs programs, policies, procedures, and controls to ensure the delivery of quality service to internal and external customers while developing and maintaining effective working relationships.

· Effectively manages staff; interviews, hires and trains; evaluates employee performance; deals with performance problems as appropriate; delegates work assignments effectively.

· Develops, directs and implements a patient safety program designed to consistently and comprehensively provide safe care to the patients at TMCH.

· Develops clear goals for the patient safety program and risk and action plan for meeting goals.

· Interfaces with quality and patient advocates to address complaints or grievance related to safety and risk.

· Analyzes and reports patient incident trends and oversees the development of action plans to reduce exposure and recurrence.

· Keeps Senior Leadership and appropriate management apprised of status of Significant Injury and Sentinel events.

· Represents TMC Health in a professional, knowledgeable manner, successfully establishes partnerships, communicates effectively, and promotes the mission and vision.

· Oversees the preparation and presentation of actionable information regarding adverse events, data and metrics that will support improvement in patient safety & experience and ensures the successful implementation of the patient safety strategic initiatives.

· Collaborates with compliance efforts related to applicable federal, state, and local regulatory requirements and responsible for coordinating organizational response to applicable regulatory inquiry.

· Develops and directs contingency plans and responds to unforeseen circumstances utilizing planned resources.

· System responsibilities as assigned.

· Adheres to TMCH organizational and department-specific safety, confidentiality, values, policies and standards.

· Performs related duties as assigned.

 

MINIMUM QUALIFICATIONS

EDUCATION:

· Bachelor’s degree in healthcare required.

· Master’s degree preferred.

EXPERIENCE:

· Five (5) years of clinical experience in patient care and two (2) or more years of risk management or patient safety experience preferably in the acute care setting.

LICENSURE OR CERTIFICATION:

· If clinician, must maintain current clinical licensure permitting work in the State of Arizona.

· CPHRM or CPHQ certification preferred.

KNOWLEDGE, SKILLS AND ABILITIES:

· Knowledge of risk assessment and process improvement best practices.

· Knowledge of reporting requirements and federal and state regulations regarding risk assessment and reporting.

· Skill in evaluating situations/events with recommendations to lessen risk to the hospital.

· Skill in facilitating and developing professional relationships.

· Ability to respond to sensitive and/or confidential inquiries or complaints from regulatory and government agencies.

· Ability to define problems, collect data, establish facts, and draw valid conclusions.

· Ability to work in a fast-paced environment utilizing tact, patience and diplomacy.

· Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

· Skill in applying and teaching exceptional customer service.

· Ability to develop, interpret and read detailed documents, contracts, proposals, and related legislative materials.

· Ability to listen and accurately interpret others’ communication or instructions to take appropriate action.

· Ability to read, analyze, and interpret; ability to write reports and business correspondence.

· Ability to speak effectively before groups of employees or customers.

· Ability to identify positive or negative variances from expected outcomes.

· Ability to solve practical problems and deal with a variety of concrete and abstract variables in situations where only limited standardization exists.