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Job Description

The Associate Director, Patient Safety has overall responsibility for the management of the Patient Safety Program in partnership with the Chief Patient Safety Officer. The Associate Director, Patient Safety develops and implements the patient safety plan and medication safety strategies including, programs, processes, education and communication across the Medical Center. The Associate Director, Patient Safety serves as a resource to senior executive management, Medical Staff, Nursing, and other Hospital and Health System personnel with regard to patient safety and medication safety matters and activities.

Principal Responsibilities:

Co-facilitates the Executive Safety Group, responsible for establishing priorities and organizing initiatives to eliminate risks and promote patient safety by: (1) Preventing the first event (2) Eliminating repeat events, and (3) Developing and maintaining a culture of safety in partnership with the Senior Vice President, Medical Affairs & Chief Medical Officer and the Senior Vice President, Operations.

Management of CSHS Patient Safety Program - Provides management and oversight of patient and medication safety activities. Coordinates patient safety efforts with various departments/stakeholders. Provides consultation to medical staff, senior and line management to incorporate concepts of safety into daily work.

Patient Safety and Medication Safety Plans, Goals, Objectives - Creates, manages and annually updates the Patient Safety Plan. Develops and implements measurable patient safety objectives consistent with the organization’s goals and timeline. Articulates organizational goals relating to patient safety. Communicates and disseminates relevant information to executive and medical staff leadership.

Patient Safety Education and Medication Safety Education - Develops a comprehensive educational program to include employee and medical staff orientation, continuing education programs, and other educational efforts as determined by senior executive management. Conducts patient safety and medication safety education for senior executive management, medical staff, nursing staff and other members of the organization. Integrates learning across Significant Adverse Event and Medication Safety Programs into Patient Safety Program. Designs a patient safety learning center in collaboration with information technology, to include a website. Stays current with safety knowledge and science, expertise, and experience in improving patient safety, and coordinating dissemination and application of such knowledge within the organization.

Sentinel Adverse Event Review Committee (SAERC)- Responsible for the agenda and support for medical staff leadership facilitating the SAERC. Manages the Significant Adverse Event (SAE), Root Cause Analysis, Sentinel Event Alert, and SAE Peer Review follow-up process.

Executive Safety Group (ESG) – Responsible for the agenda content of the ESG meetings with operational focus. Participates in pre-ESG meetings to develop a collaborative relationship with operational executives and clinical leaders to review rationale, gain insight, and begin negotiation to achieve consensus, particularly for RCA action follow-up items and other major safety initiatives accountable to the Executive Safety Group and its members.

Continuous Quality Improvement - Develops, implements, monitors, and champions performance improvement processes and policies relating to key patient safety issues. Adopts principles of Continuous Quality Improvement in all areas of responsibility.

Data Quality Management - Monitors, benchmarks, trends, and reports performance relative to patient safety indicators. Develops and maintains a Patient Safety Dashboard.

Case Review Screening - Manages the screening process for peer review to include; appropriate capture of cases, clinical screening according to criteria or knowledge/expertise, use of appropriate technology, review and identification of patterns or trends, generation of worksheets, preparation of all information and materials necessary for peer review, data entry into MIDAS is accurate and timely and established timeframes and appropriate volume are maintained.

Peer Review: Collaborates with Peer Review Department to coordinate on case investigations involving a peer review component as directed by the Chief Patient Safety Officer and Medical Directors of Medical Affairs.

Culture of Safety Survey-In collaboration with Organizational Development, plan, coordinate and assist with implementation of the biennial Culture of Safety Survey, working with clinical and operational leaders to identify opportunities and develop action plans.

Responsible for Incident Reporting System for Cedars-Sinai Medical Center, Marina Del Rey Hospital, and Medical Network. Oversees data system integrity and ensures quality assurance measures are followed based on departmental operating procedures. Provides routine reporting to support recommendations, trends and regulatory requirements. Develops and maintains all policies and procedures related to incident reporting.

Legal and Regulatory Compliance - Establishes and maintains systems to ensure organization compliance with legal and regulatory standards, hospital policies and procedures. Serves as a resource person for addressing The Joint Commission, California Department of Public Health, and Tittle 22 standards and requirements relating to patient and medication safety.

Policies and Procedures - Responsible for developing, maintaining, and implementing current policies and procedures and maintaining a manual.

Fiscal Management - Assists with preparation and controlling the Department's operational and capital equipment budgets

Qualifications

Education:

Bachelor's Degree, Nursing, Required
Master's Degree, MPH, MHA, MBA, or MSN -Preferred

Work Experience:
5 years of Hospital wide experience with the Joint Commission Standards, Required 

8 years of Acute Care Complex Setting in Quality Improvement, Management, or Nursing Education/Position, Required

2 years of experience in leading quality and service improvement activities and achieving outcomes which correspond to customer expectations, Required

Licenses and Certifications:
Certified Professional in Patient Safety CHPQ -  within 1 1/2 years of hire, Required 
Certified Professional in Healthcare Quality CPPS – within 1 1/2 years of hire -Preferred