Director Patient Safety

About the role

The Patient Safety Director leads and collaborates in the implementation of the hospital-based patient safety program with the goal of eliminating preventable patient harm while also establishing and sustaining a culture of safety.

Responsibilities

• Systems Thinking and Reliable Design: Prevent future harm by initiating and overseeing proactive evaluation and redesign of systems to improve care processes (e.g., forcing functions, checklists, error causation thinking, human factors, applied informatics, culture).
• Support improved outcomes by emphasizing both appropriate behaviors and robust systems that include concise accountability measures and follow‑up.
• Improve consistent delivery of evidence‑based care and reduction in preventable harm by focusing on reliability and applying the principles of reliable design.
• Reduce variation in care delivery.
• Partner with the Patient Safety Organization (PSO) to explore identified variations when appropriate.
• Utilize alerts and best practices (e.g., Sentinel Event Alerts) to perform gap assessments and implement strong actions that will alleviate identified gaps.
• Identification and Mitigation of Patient Safety Risk: Effectively report, investigate, and analyze patient safety incidents, medical errors, and potential risks in the facility.
• Facilitate thorough and credible serious event analysis that result in strong sustainable improvement strategies.
• Facilitate thorough and credible failure mode effect analysis to identify and mitigate unintended adverse patient outcomes and evaluate effectiveness of process changes.
• Perform Patient Safety Rounds that identify patient safety risks.
• Empower staff to identify and participate in resolution of patient safety concerns.
• Coordinate disclosure of serious events to patients and/or families in accordance with organizational policy and regulations.
• Assure timely reporting of Patient Safety Work Product (PSWP) to the PSO.
• Actively participate in PSO learning collaboratives.
• Ensure implementation of best practices, alerts, and updates to drive patient safety improvement.
• Safety Culture Advancement: Champion completion of Culture of Safety Survey.
• Facilitate analysis of culture of safety survey results such that data‑driven action plans lead to targeted outcomes.
• Support and encourage harm reporting throughout the organization through a non‑punitive, just event reporting system.
• Provide feedback that acknowledges both the value of event reporting and review of reported events.
• Facilitate thorough and credible review of events that address both system and individual accountability.
• Serves as chair, or co‑chair, of the Patient Safety Committee.
• Develop and/or provide input into organizational policies and procedures related to patient safety and/or risk management.
• Patient Safety Education: Include patient safety in new hire orientation presentation (e.g., PSO membership, reporting expectations, safety culture).
• Provide ongoing education to leaders, medical staff, and staff on the science of safety (high reliability, effective communication, sustaining awareness/alertness) and patient safety initiatives.
• Partnership with Executive and Clinical Leaders: Work with facility leaders and managers to ensure thorough, credible and timely event management.
• Join with facility leaders to identify and hardwire behavioral norms that promote a culture of safety.
• Work with facility leaders to ensure understanding of and compliance with the National Patient Safety Goals.
• Partner with facility leadership to establish activities that enable and sustain an open and fair environment promoting learning, safe systems, and appropriately managing behavioral choices related to patient safety (e.g., Patient Safety Rounds, Event Response, Disclosure).
• Partner with Quality to complete the NQF Safe Practices section of the Leapfrog Hospital Survey.
• Participate in clinical and non‑clinical committees to report applicable patient safety data, analyses, and information and to provide patient safety and risk management guidance and input.
• Patient and Family Engagement: Engage patients/families when appropriate in the patient safety program.
• Seek input from patients/families involved in harm or close call events as appropriate.
• Oversee the complaint and grievance process including investigation and resolution.
• Ensure strict compliance to related CMS Conditions of Participation.
• Measurable Reduction in Avoidable Harm: Oversee the management and use of event information to benchmark and track progress to zero avoidable harm.
• Provide analysis and identify trends from patient safety data and reports to track progress of improvement strategies.
• Spread and sustain improvement.
• Present informative and actionable patient safety reports to appropriate committees to include high level presentations to Leadership, Medical Executive Committee and Board of Trustees.
• Include the patient’s story of harm.
• Implements and ensures ongoing systems to comply with requirements of the Safe Medical Device Act (SMDA) and tracks and/or reports recalls and/or issues associated with the safety of medical devices and products.
• Works collaboratively with all other hospital departments who have responsibility for SMDA tracking and/or reporting.
• Risk Management/Claims Activities: Work with defense legal counsel to coordinate the investigation, processing and defense of claims against the facility; records, collects, documents, maintains, and provides to defense attorneys any requested information and documents necessary manage facility claims while maintaining privilege of PSWP.
• Notify and interact with HCI on all actual and potential claims.
• Work with security on procedures to reduce the frequency and/or minimize the severity of property loss or assets.
• Contract Review: Manage non‑HCI cases: accept/process subpoenas, visitor events, property loss or theft, etc.
• Oversee the process for investigating and resolving concerns related to patient belongings.

Requirements

• Bachelor’s Degree in healthcare related field – Required
• 3‑5 years healthcare experience in patient safety, risk, and/or quality (recent and within a clinical setting such as Hospital, Ambulatory Surgery Center, etc.) – Preferred
• Certification in Patient Safety (CPPS) – Required; if not already CPPS, must obtain certification within 12 months of hire

Qualifications

• Master’s Degree – Preferred
• Clinical Background – Preferred

Benefits

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services
• Wellbeing support, including free counseling and referral services
• Time away from work programs for paid time off, paid family leave, long‑ and short‑term disability coverage and leaves of absence
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft