Director Patient Safety

HCA Austin , TX 78719

Posted 5 months ago

Since 1924, St. David's Medical Center has proudly provided Central Texans with exceptional medical care.

Centrally located at 32nd Street & IH-35, St. David's Medical Center offers comprehensive services, a 24-hour Emergency Department, and leading-edge care in women's services, neurosciences, cardiovascular services, orthopedics and rehabilitation. The medical center campus features a comprehensive stroke center, a Certified Chest Pain Center, the full-service St. David's Rehabilitation Center, comprehensive Breast Center, and the largest Level IV Neonatal Intensive Care Unit (NICU) in the region.

We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us.

Your benefits include 401k, PTO medical, dental, flex spending, life, disability, tuition reimbursement, employee discount program, employee stock purchase program and student loan repayment. We would love to talk to you about this fantastic opportunity.

JOB SUMMARY (Primary purpose of the position.)

Advance a patient safety program that promotes a culture of safety and the elimination of avoidable harm.

GENERAL RESPONSIBILITIES (The essential responsibilities and accountabilities of this position including interactions with other departments and outside vendors, if applicable, in PRIORITY order.)
1.Systems Thinking and Reliable Design Expectations

a. 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).

b. Support improved outcomes by emphasizing both appropriate behaviors and robust systems that include concise accountability measures and follow-up.

c. Improve consistent delivery of evidence-based care and reduction in preventable harm by focusing on reliability and applying the principles of reliable design.

d. Reduce variation in care delivery. Partner with the Patient Safety Organization to explore identified variations when appropriate.

e. Utilize alerts and best practices (e.g. Sentinel Event Alerts) to perform gap assessments and implement strong actions that will alleviate identified gaps.
2.Identification and Mitigation of Patient Safety Risk Expectations

f. Effectively report, investigate, and analyze patient safety incidents, medical errors and potential risks in the facility.

g. Facilitate thorough and credible serious event analysis that result in strong sustainable improvement strategies.

h. Facilitate thorough and credible failure mode effect analysis to identify and mitigate unintended adverse patient outcomes and evaluate effectiveness of process changes.

i. Perform Patient Safety Rounds that identify patient safety risks. Empower staff to identify and participate in resolution of patient safety concerns.

j. Coordinate disclosure of serious events to patients and/or families in accordance with organizational policy and regulations.

k. Assure timely reporting of Patient Safety Work Product (PSWP) to the Patient Safety Organization.

l. Actively participate in PSO learning collaborative. Ensure implementation of best practices, alerts, and updates to drive patient safety improvement.
3.Safety Culture Advancement Expectations

a. Champion completion of Culture of Safety Survey.

b. Facilitate analysis of culture of safety survey results such that data-driven action plans lead to targeted outcomes.

c. Support and encourage harm reporting throughout the organization through a nonpunitive just event reporting system.

d. Provide feedback that acknowledges both the value of event reporting and review of reported events.

e. Facilitate thorough and credible review of events that address both system and individual accountability.
4.Patient Safety Education Expectations

a. Include patient safety in new hire orientation presentation (e.g. PSO membership, reporting expectations, safety culture)

b. Provide ongoing education to leaders, clinicians and staff on the science of safety (high reliability, effective communication, sustaining awareness/alertness) and patient safety initiatives.
5.Partnership with Executive and Clinical Leaders Expectations

a. Work with facility leaders and managers to ensure thorough, credible and timely event management.

b. Join with facility leaders to identify and hardwire behavioral norms that promote a culture of safety.

c. Work with facility leaders to ensure understanding of and compliance with the National Patient Safety Goals.

d. 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).

e. Partner with Quality to complete the NQF Safe Practices section of the Leapfrog Hospital Survey.
6.Patient and Family Engagement Expectations

a. Engage patients/families when appropriate in the patient safety program.

b. Seek input from patients/families involved in harm or close call events as appropriate.
7.Measureable Reduction in Avoidable Harm Expectations

a. Oversee the management and use of event information to benchmark and track progress to zero avoidable harm.

b. Provide analysis and identifying trends from reports (e.g. event reports, SHARP report, Service Line Dashboards) to track progress of improvement strategies. Spread and sustain improvement.

c. 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.
8.Risk Management/Claims Activities (if not otherwise assigned)

a. 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

b. Notify HCI of all actual and potential claims

c. Work with security on procedures to reduce the frequency and/or minimize the severity of property loss or assets

d. Contract Review

e. Manage non-HCI cases: accept/process subpoenas, visitor events, property loss or theft, etc.
9.Regulatory

a. Dedicated to providing coordination, monitoring of, and oversight for ongoing readiness to satisfy requirements of various accrediting bodies (Joint Commission, CMS, TDH, etc.)

b. Promote Patient Safety and Quality campus wide.

c. Collects, analyzes and evaluates data to develop recommendations for improvement within the department and throughout the St. David's Medical Center enterprise.

d. Primary liaison with the Joint Commission, updating and monitoring organizational information affecting Joint Commission accreditation. Provide primary reporting on all Joint Commission related activities including planned/unplanned surveys, Annual Periodic Performance Review

e. Oversees compliance with TJC standards on a continuous basis throughout the acute care and ambulatory settings, maintains TJC Intracycle Monitoring (ICM) database and monitors TJC survey readiness plans.

f. Represents the facility as a key contact in the coordination of TJC Core Measures and CMS Quality initiatives.

Maintains current working knowledge of TJC, NCAQ, CMS and other accreditation and regulatory standards applicable to hospital and physician office group practices. Maintains current accessible copies of regulatory standards as a resource for staff.

Experience Required:
3-7 years: Clinical Background

Other required experience:
3-5 years healthcare experience in patient safety, risk, and / or quality preferred. Healthcare experience should be recent and within a clinical setting such as a Hospital, Ambulatory Surgery Center, etc.

Education Required:

Bachelor's Degree-Major: Healthcare related field

Master's Degree Preferred

Licenses and Certifications:

Certified in Patient Safety (CPPS) - required within 12 months of hire



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Director Patient Safety

HCA