Responsible for improving the culture of safety by implementing the planestablished 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 a 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 a 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 a subsidiary Patient Safety & Clinical Risk director or manager:

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.