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Position** **Summary:

Responsible

for

improving

the

culture

of

safety

by

implementing

the

plan

established by the MHC Quality Improvement and Patient Safety Program (QIPSP) at assigned

subsidiary(ies).

Responsibilities

include

program

oversight,

analysis

of

data,

implementation

of

plans,

local

systems

and

processes,

and

coordinate

action

plans

to

improve

safety.

Conducts

patient

safety

rounds and assessments, ensuring compliance with patient safety-related standards to reduce risk and

improve safety.

Essential** **Functions** **and** **Responsibilities as** **Assigned:

1.

Assists

in

the

implementation

of

MHC

QIPSP

to

produce

measurable

improvements

in safety culture.

2.

Reviews reported safety concerns to identify trends and opportunities for aggregate analysis.

Offers

recommendations

to

dyad

leader

and

the

appropriate

executive

and

safety committees, as directed.

3.

Coordinates

patient

safety

improvement

activities

to

promote

event

reporting

and learning from system defects to reduce the risk of harm.

4.

Implements

policies,

procedures,

and

protocols

as

they

relate

to

patient

safety

and

clinical risk activities.

5.

Promotes

patient

safety

activities

for

staff,

leaders

and

physicians,

utilizing

safety

culture principles and safety reporting data.

6.

Develops,

manages,

and

presents

education

programs

to

new

and

current

staff

and

leaders addressing subsidiary safety concerns and strengthening safety reporting.

7.

Reviews

and

manages reported

safety

event

files

in

timely

manner.

8.

Investigates,

develops

and

facilitates

root

cause

analysis

process.

Components

of

causal analysis include assessing for contributing factors related to staffing, healthcare equity/disparities, and/or system weaknesses.

9.

Provides

consultation

regarding

crisis

situations,

as

requested.

Acts

as

resource

for physicians needing to disclose unanticipated outcomes with patients and/or family.

10.

Collaborates

with

clinical

leadership

to

develop

strategies

to

minimize

harm

events.

11.

In

absence

of

subsidiary

Patient

Safety

&

Clinical

Risk

director

or

manager:

Serves

as

subsidiary

Patient

Safety

Officer

to

monitor

that

clinical

services

are provided in accordance with safety standards established by federal, state and regulatory agencies

Participates

and

presents

at

meetings

and

committees

that

align

with

the subsidiary’s patient safety program

Represents

department

at

committees,

as

requested,

while

maintaining

integrity

of the information in a confidential, peer protected manner.

12.

Performs

other

duties

as

assigned.

_Required:_

* Bachelor’s

degree

* Two

years

of

healthcare

experience.

* Certified Professional in Patient Safety (CPPS), Certified Professional in Healthcare Risk

Management

(CPHRM),

Certified

Professional

in

Healthcare

Quality

(CPHQ)

or other patient safety training/certification. If not currently holding certification, must obtain within 2 years (full-time) or 3 years (part-time) from date of hire.

_Preferred:_

* Bachelor’s

degree

in

clinical or

healthcare

focus.

* Three

years

of

healthcare

experience,

specific

to

patient

safety

and/or

healthcare

risk

management.