Manager, Patient Safety

Memorial Home Services; Springfield (IL); On-site; USD 90,000 - 120,000; Full time

Job summary

Memorial Health is seeking a Manager of Patient Safety and Accreditation to lead the patient safety program, promote safe practices and foster a just culture throughout the health system.

The role ensures regulatory compliance, readiness activities, and guides survey processes with leaders across Memorial Health. Strong experience in accreditation and safety science is required.

Qualifications

• Bachelor’s degree in nursing or healthcare is required.
• Illinois license in the respective profession is highly preferred but not required.
• CPPS and/or CPHQ certifications are required.
• Certified Just Culture certification is required.
• Over five years of healthcare-related experience is required.
• Minimum of two years of supervisory/management experience is required.
• Experience with systematic reviews of patient safety events is required.
• Experience applying quality improvement principles and safety science concepts.
• Experience with accreditation/regulatory compliance activities (JCO, CMS, state regs) is required.
• Experience collaborating with physicians and operational leaders in interdisciplinary settings.

Responsibilities

• Lead Memorial Health’s patient safety program and promote safe practices.
• Nurture a just culture and improve processes to detect, mitigate or prevent harm.
• Ensure operational compliance with regulations and standards; guide readiness activities.
• Coordinate accreditation/regulatory survey processes and responses to findings.
• Develop action plans with leaders to maintain ongoing compliance.
• Communicate interpretations and updates of standards to the organization.
• Coach and develop team members and maintain PSES integrity.
• Coordinate responses to inquiries related to quality-of-care concerns.
• Oversee reviews of patient safety events and root/cause analyses as warranted.
• Disseminate data and promote a culture of safety across the health system.

Skills

Leadership

Patient safety

Regulatory knowledge

Clinical background

Data analysis

Team coaching

Education

Bachelor's degree in nursing or healthcare

Job description

The Manager of Patient Safety and Accreditation leads Memorial Health’s patient safety program, promotes safe practices, nurtures a just culture and improves processes that detect, mitigate or prevent harm. The Manager enables operational compliance with regulations and standards, facilitates constant readiness activities and guides the organization through the survey process and findings.

• Maintains a current working knowledge of Joint Commission Standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participation, and Illinois Hospital Licensing Act requirements.
• Serves Memorial Health as a subject matter expert and internal resource.
• Oversees accreditation/regulatory compliance assessments to maintain a state of constant readiness in coordination operational leaders across the health system.
• Facilitates organizational efforts in communicating new and pending standard interpretations, updates and clarifications.
• Collaborates with operational leaders to develop action plans to support ongoing compliance with accreditation and regulatory requirements.
• Leads accreditation/regulatory survey process.
• Coordinates correspondence with regulatory and accrediting bodies regarding plans of correction and/ or evidence of standards compliance.
• Coordinates response to external inquiries related to quality-of-care concerns.
• Maintains the integrity of the Memorial Health’s Patient Safety Evaluation System (PSES). Informs and educates Memorial Health leaders on the PSES policy.
• Oversees the review of patient safety events and delegates apparent cause analyses, root causes analyses and proactive risk assessments as warranted.
• Coordinates quality indicator reviews and tracer activities related to organizational patient safety priorities, aggregates and disseminates data as warranted.
• Promotes a culture of safety and serves as an expert in just culture.
• Coaches and develops team members.
• Performs other related work as required or requested.

Minimum Qualifications:

• Bachelor’s degree in nursing or healthcare field required.

Education:

• Current Illinois license in respective profession is highly preferred but not required.

Licensure/Certification/Registry:

• Certified Professional in Patient Safety (CPPS) and/or Certified Professional in Healthcare Quality (CPHQ) required.
• Certified Just Culture required.

Experience:

• More than five (5) years of healthcare related experience is required
• Minimum of two (2) years of previous supervisory/management experience is required
• Demonstrated experience with conducting comprehensive systematic reviews of patient safety events
• Demonstrated experience in applying quality improvement principles
• Demonstrated experience with applying safety science principles including just culture
• Demonstrated experience in healthcare accreditation/regulatory compliance activities including but not limited to Joint Commission, Center for Medicare and Medicaid Services (CMS) and state regulations
• Demonstrated experience working effectively with physicians and operational leaders in an interdisciplinary environment

Other Knowledge/Skills/Abilities:

• Possesses an expert knowledge of patient safety and quality improvement principles and practices
• Possesses a working knowledge of accreditation and regulatory standards
• Demonstrated problem solving skills and ability to consistently exercise sound judgment and initiative in all circumstances, including very stressful situations. Able to effectively manage competing priorities.
• Demonstrated effective written and verbal communication in performing assigned duties.
• Demonstrated ability to effectively communicate, collaborate and work through complex and sensitive situations with individuals and groups in a confidential and respectful manner.
• Demonstrated skills in developing and maintaining good interpersonal relationships
• Demonstrated skills in leadership, organization and team building