Patient Safety Manager

Hampton, Virginia Overview
The Patient Safety Manager works under the supervision of the Director of Quality and is responsible to investigate, resolve, document and report Riverside Mental Health Recovery Center specific patient and visitor safety events. This role is the champion for patient and team member safety and responsible for the implementation of the safety program, following evidenced based safety behaviors and practices focusing on people, process, and technology to improve safety related performance where just culture principles are applied and evident throughout the organization. Follows all Department of Behavioral Health (DBHDS) regulations and guidelines. Responsible for the oversight and entries within the internal incident reporting system.

What you will do

• Safety Management - Serve in both a proactive and reactive manner in order to pre-identify issues and in a reactive manner to facilitate performance improvement and service recovery. Responsible for the daily management of all event reporting both internally and externally and related to processes and business rules related to the components of the safety event feedback loop. Responsible for the detection of safety issues through case finding and surveillance, quality screens and other methods identified. Verifies all reported safety events and prepares a weekly summary report for review at the case review meetings. Identifies critical events that require RCA/ACA review and those events that may require referral to medical peer review and events that are potentially compensable that require referral to risk management/legal. Prioritizes, leads and conducts investigations applying just culture principles to identify root causes and contributory factors. Formulates safety solutions and system improvements, implementing changes in work systems to correct system and process vulnerabilities and monitoring the effectiveness of solutions to prevent reoccurrence. Assures ongoing and up to date knowledge of required safety reporting programs and specific safety reporting measures. Knows where to obtain safety event measure specifications. Assures appropriate and up to date content for facility education, training and communication related to the all safety event reporting systems. Applies systems thinking and accounts for human factors in all aspects of the safety programs.
• Safety Culture - Maintains knowledge of safety culture survey tools and methods. Coordinates and participates in annual assessment of safety culture as needed and assigned. Promotes safety culture and supports system wide and facility wide efforts to assure just culture and safety culture principles and practices are supported and evident throughout. Assures appropriate distribution and communication of safety culture survey results. In collaboration with unit, department and facility leadership, develops, implements and monitors action plan based on safety culture results that includes just culture training, team trainings such as TeamSTEPPS and training related to safety event reporting. Designs and implements safety program that raises awareness.
• Performance Improvement - Oversees facility safety program, assures structure supports required reporting for programs. Oversees and supports safety risk assessment and identifies risks and improvement opportunities based on analysis of facility data, emerging national, state and local quality of care trends and issues. Selects appropriate safety, quality performance and process improvement methods and tools. Facilitates the use of process analysis tools to display data (e.g.- fishbone, run chart, control chart). Provides oversight of safety related improvement projects and efforts, assuring alignment and coordination throughout facility. Facilitates establishment of priorities for safety improvement activities and development of safety performance improvement action plans and projects. Facilitated development of safety related policies, practices, work flow and guidelines incorporating safety behaviors, and human factor design and engineering.
• Data Measurement and Analytics - Oversees safety data and complaint and grievance data; assures data is accurate, timely and displayed in a meaningful way to end users. Has deep knowledge and understanding of safety data applications and serves as the content expert on navigation and use of rCare and CHRIS systems. Interprets and presents data to support decision making. Assures action is taken in improvement opportunities are identified.
• Process Improvement - Serve in both a proactive and reactive manner in order to pre-identify issues and in a reactive manner to facilitate performance improvement and service recovery. Conducts facility rounds, engages team members, and creates an environment that is safe for all patients and residents. Oversees and coordinates performance improvement activities in an effort to enhance quality and reduce and/or prevent medical errors. Participates and leads projects related to Performance Improvement/outcome measures, licensure/accreditation, Risk Management, and Medical Record documentation. Ensures timely PI data collection and entry for licensure and regulatory agencies such as: DNV, CMS, Core Measures, and RHS/RBHC quality and scorecard indicators. This position will analyze data from multiple sources, aggregate the data and present the data in a usable format. Participates in licensure and accreditation surveys, to include data collection, outcome results, analysis, action, and follow-up implementation.
• Education and Training - Support a learning environment focused on team member and patient safety, providing training for new hires, and as needed for team members and medical staff on safety measures, complaint and grievance processes, service recovery, and reporting requirements. Develops annual plan for education and training related to patient and team member safety and patient complaint, grievances and quality initiatives. Design, coordinate and provide just culture, safety and safety improvement related training to all team members, including leadership and physicians. Implement and supports the safety program that includes action planning and team training related to safety event reporting. Provides a written evaluation on the effectiveness of the training and education.

Qualifications

Education

• Bachelors Degree, Nursing, healthcare or related field (Required)
• Masters Degree, Relevant field (Preferred)

Experience

• 2 years Relevant experience in hospital healthcare quality, safety and/or risk management (Required)
• 1 year Project development, project management, and strong analytical skills (Preferred)
• 1 year Knowledge of patient safety and advocacy requirements (Required)

Licenses and Certifications

• Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Virginia or Multi-State Upon Hire(Required)
• CPR/BLS Certification - American Heart Association/American Red Cross/American Safety and Health Institute (AHA/ARC) within 30 Days(Required)
• Certified Professional in Patient Safety (CPPS) - Institute for Healthcare Improvement (IHI) within 180 Days(Required)
• Lean and/or Six Sigma certification (Preferred)
• change/or project management (Preferred)

To learn more about being a team member with Riverside Health System visit us at .