Advance a patient safety program that promotes a culture of safety and the elimination of avoidable harm
Systems Thinking and Reliable Design Expectations:
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).
Support improved outcomes by emphasizing both appropriate behaviors and robust systems that include concise accountability measures and follow-up.
Improve consistent delivery of evidence-based care and reduction in preventable harm by focusing on reliability and applying the principles of reliable design.
Reduce variation in care delivery. Partner with the Patient Safety Organization to explore identified variations when appropriate.
Utilize alerts and best practices (e.g. Sentinel Event Alerts) to perform gap assessments and implement strong actions that will alleviate identified gaps.
Identification and Mitigation of Patient Safety Risk Expectations:
Effectively report, investigate, and analyze patient safety incidents, medical errors and potential risks in the facility.
Facilitate thorough and credible serious event analysis that result in strong sustainable improvement strategies.
Facilitate thorough and credible failure mode effect analysis to identify and mitigate unintended adverse patient outcomes and evaluate effectiveness of process changes.
Perform Patient Safety Rounds that identify patient safety risks. Empower staff to identify and participate in resolution of patient safety concerns.
Coordinate disclosure of serious events to patients and/or families in accordance with organizational policy and regulations.
Assure timely reporting of Patient Safety Work Product (PSWP) to the Patient Safety Organization.
Actively participate in PSO learning collaboratives. Ensure implementation of best practices, alerts, and updates to drive patient safety improvement.
Safety Culture Advancement Expectations:
Champion completion of Culture of Safety Survey.
Facilitate analysis of culture of safety survey results such that data-driven action plans lead to targeted outcomes.
Support and encourage harm reporting throughout the organization through a nonpunitive just event reporting system.
Provide feedback that acknowledges both the value of event reporting and review of reported events.
Facilitate thorough and credible review of events that address both system and individual accountability.
Patient Safety Education Expectations:
Include patient safety in new hire orientation presentation (e.g. PSO membership, reporting expectations, safety culture)
Join with facility leaders to identify and hardwire behavioral norms that promote a culture of safety.
Work with facility leaders to ensure understanding of and compliance with the National Patient Safety Goals.
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).
Partner with Quality to complete the NQF Safe Practices section of the Leapfrog Hospital Survey.
Provide ongoing education to leaders, clinicians and staff on the science of safety (high reliability, effective communication, sustaining awareness/alertness) and patient safety initiatives.
Partnership with Executive and Clinical Leaders Expectations:
Work with facility leaders and managers to ensure thorough, credible and timely event management.
Bachelor’s Degree in Healthcare related field required. Master’s Degree preferred.
Certification in Patient Safety (CPPS) required;
If not already CPPS, must obtain certification within 12 months of hire.
Other licenses/certifications required by State
TeamSTEPPS Master Trainer (If not already a Master Trainer, must obtain with 12 months of hire.)