Director Patient Safety/Regulatory

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.

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.

Education

• Bachelor’s degree in healthcare required.
• Master’s degree preferred.

• 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.

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

• CPHRM or CPHQ certification preferred.