Overview Supports Decatur Memorial Hospital's patient
safety program. Facilitates proactive patient safety risk
assessments, monitors reported patient safety events, and analyzes
patient safety event trends. Participates in the systematic
investigation of adverse patient safety events, including root
cause analysis. Works in collaboration with the Director of Quality
& Safety and Accreditation in assuring ongoing compliance
with The Joint Commission (TJC) accreditation standards, Illinois
Hospital Licensing Act requirements, and the Center for Medicare
and Medicaid (CMS) Conditions of Participation.
* Master's degree in nursing or health care field is
preferred. * An associate's degree in nursing or health
care field with at least 10 years of directly related work
experience may be considered in lieu of a master's
* Current Illinois license in respective profession is highly
preferred but no required. * Lean Six Sigma White Belt required
within 6 months of hire. * Lean Six Sigma Green belt required
within 24 months of hire. * Certified Professional in Patient
Safety (CPPS) is preferred.
* Minimum of two years of healthcare related experience is
required. * Minimum of three years healthcare leadership experience
is preferred. * Three years of demonstrated experience in hospital
accreditation/regulatory compliance activities is preferred. *
Demonstrated experience working effectively with physicians and
other healthcare leaders in a multidisciplinary environment is
* Demonstrated knowledge in Patient Safety and Quality
Improvement principles and practices. * Demonstrated critical
thinking, decision-making, problem solving, and conflict resolution
skills. * Self-directed and motivated individual with excellent
organizational skills. * Proficiency in utilizing common business
and clinical software, including but not limited to, data bases,
spreadsheets, and statistical analysis and display. * Excellent
written communication; demonstrated ability to write clearly and
concisely, communicating complex concepts accurately. * Sound
verbal communication and presentation skills; ability to speak
clearly and persuasively in positive or negative situations.
Ability to effectively communicate, collaborate and work through
complex and sensitive situations with individuals and groups. *
Ability to analyze complex clinical and organizational events. *
Expertise in facilitation and management of group processes focused
on systems thinking and objectively assessing and modifying
workflow processes to improve safety and quality. * Proficiency in
reading, analyzing, and interpreting regulatory documents;
experience in investigating and preparing response inquiries.
* 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. Provides updates and clarifications on issues of
concern to individuals and groups within the health system.
Supports organizational efforts in communicating new and pending
standard interpretations, updates and clarifications.
* Assists the Director of Quality & Safety in
facilitating frequent system-wide assessments to quantitatively and
qualitatively assess regulatory compliance to maintain a constant
state of readiness. These activities are completed in coordination
with the ongoing work of the DMH Teams on survey readiness,
Memorial Health System quality & safety and operational
* Works in collaboration with department leaders in developing
action plans related to assuring ongoing compliance with
accreditation and regulatory requirements.
* Serves as a leader of the DMH safety committee. Serves as a
subject matter expert related to ongoing revisions and additions to
Joint Commission standards as they relate to ongoing
* Assists in the dissemination of Joint Commission Sentinel
Event Alerts and National Patient Safety Goals. Facilitates
proactive risk assessments related to TJC Sentinel Event Alerts.
Assists in the ongoing monitoring of compliance with Joint
Commission standards and CMS Conditions of Participation.
* Produces presentation materials related to patient safety
science concepts and accreditation/ regulatory activities for
internal committees, work groups, medical staff and leader
* Participates in activities related to the culture of safety
survey including but not limited to pre-survey preparation, survey
execution and post-survey action planning.
* Facilitates prevention, identification and reporting of safety
issues and problems, role-modeling non-punitive approaches to
* Assists the System Director of Patient Safety and
Accreditation in the execution of the Support for Second Victims
program and serves as a Trained Supporter.
* Participates in audits and tracer activities related to
organizational patient safety priorities, aggregates and
disseminates data related to these audits.
* Gathers data detailing patient-related errors, and conducts
analysis detailing the cause of the error; recommends changes to
procedures, policies, and/or programs that could prevent future
* Facilitates analyses of actual and potential patient safety
occurrences to improve systems and processes (e.g., Patient Safety
Debriefings, Cause Mapping, Failure Modes and Effects
* Facilitates the investigation and preparation for presentation
of the systematic comprehensive review and analysis of serious
patient safety events to the Root Cause Analysis Leadership Team.
Facilitates the efforts of RCA Action Teams when they are
* Serves as a patient safety representative on value stream
management teams as indicated.
* Performs other related work as required or requested.
The intent of this job description is to provide a
representative summary of the major duties and responsibilities
performed by incumbents of this job. Incumbents may be requested to
perform tasks other than those specifically presented in this