Patient Safety Coordinator
Company: Memorial Health
Posted on: May 5, 2021
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
- 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 degree.
- Current Illinois license in respective profession is highly
preferred but no required.
- Lean Six Sigma White Belt required within 6 months of
- Lean Six Sigma Green belt required within 24 months of
- Certified Professional in Patient Safety (CPPS) is preferred.
- Minimum of two years of healthcare related experience is
- Minimum of three years healthcare leadership experience is
- 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
preferred. Other Knowledge/Skills/Abilities:
- 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
- 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
- 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
- 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
- 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
Keywords: Memorial Health, Decatur , Patient Safety Coordinator, Other , Decatur, Illinois
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