Program Manager Patient Safety Clinical Risk Registered Nurse - Risk Management

Department: Risk Management

Daily Work Times: 8:00am - 4:00pm

Shift: Days

Hours Per Pay Period: 80

Position Summary:  

Provides administrative leadership, direction, and supervision in the integration of the overall Risk and Patient Safety program for the facility. Responsible for development of annual site specific Patient Safety Plan. Coordinates patient safety improvement programs that reduce the risk of injury and promote reporting of incidents.  Develops and delivers education programs based on incident reporting data.  Administers the Safety First Program including the performance of investigations and Root Cause Analysis. 

Essential Functions and Responsibilities:

1. Provides leadership and oversight for all patient safety endeavors at the site including:
   1. Prevention, Detection and Correction of Patient Safety events
   2. Staff education in error reduction
   3. Culture of Safety
   4. Just Culture
   5. Daily Check-ins
2. Assists in the development and implementation of Patient Safety Annual Goals and Objectives in line with McLaren Strategic Plan
3. Responsible for development of the Patient Safety Plan and Areas of Focus
4. Patient Safety Identification/Event Management
5. Reviews incident trends for patients, employees and visitors and makes recommendations to administration for case status
6. Identify adverse trends or individual patient safety concerns through Safety First, chart abstraction, referrals from management or hospital personnel, and any others identified.
7. Notifies administration of quality or regulatory issues as appropriate when negative trends or events occur which need intervention and monitoring.
8. Responsible for identifying and aggregating adverse trends and/or patient safety concerns for presentation to CMO and Patient Safety & Quality Committee
9. Reports trends and recommendations to the appropriate executive and safety committees
10. Compiles information from staff, managers, unit managers, site administrators and physicians on patient safety concerns and provides recommendations to leadership for next steps
11. Conducts initial investigation of all potential patient safety events and provides summaries and recommendation to CMO and site administration ongoing.
12. Investigations include but are not limited to: internal and external medical record review, staff and witness interviews, and other communication as appropriate
13. Facilitates the Root Cause Analysis process in conjunction with CMO & CNO
14. Works independently to promote patient safety to various hospital staff, hospital administration and to physician groups, utilizing culture of safety information.
15. Develops/manages and presents education programs and other educational materials addressing areas of concern in patient safety
16. Provides risk and patient safety orientation to newly hired employees
17. Provides consultation regarding crisis situations (sentinel events,    medical events, internal disaster, external disaster)
18. Acts as system resource for disclosure process and learnings
19. Initiates and oversees the development of a patient safety improvement program inclusive of the analysis and trending of data related to hospital initiatives.
20. Proactively addresses patient safety utilizing data, information from Patient Safety Committees, Executive Rounding and other reports to analyze issues and determine their root causes.
21. Collaborates with clinical leadership to develop strategies to minimize incidents. Develops programs and services that produce measurable improvements processes and practices that affect patient safety.
22. Serves as a liaison to ensure clinical services are provided in accordance with safety standards established by federal and state regulatory agencies and the Joint Commission accreditation standards, including the National Patient Safety Goals.
23. Communicates with and educates leadership and staff regarding patient safety initiatives and activities.
24. Co-chairs the patient safety committee with CMO.
25. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.