Director of Patient Safety & Risk Management
Idaho Falls , Idaho
November 18, 2017
Eastern Idaho Medical Center

The largest medical facility in the region, Eastern Idaho Regional Medical Center (EIRMC) is a modern, Joint Commission-accredited, 330-bed full-service hospital located in Idaho Falls. Idaho Falls offers a rich variety of outdoor activities with Grand Teton National Park, Yellowstone National Park, Jackson, WY and Sun Valley all within a short drive from our hospital.

JOB SUMMARY (Primary purpose of the position.)

- Advance a patient safety program that promotes a culture of safety and the elimination of avoidable harm.
Major Responsibilities

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 information, 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 collaborative's. 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 non punitive 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)
- 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.
- 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, and Disclosure).
- Partner with Quality to complete the NQF Safe Practices section of the Leapfrog Hospital Survey.

Patient and Family Engagement Expectations:
- Engage patients/families when appropriate in the patient safety program.
- Seek input from patients/families involved in harm or close call events as appropriate.

Measurable Reduction in Avoidable Harm Expectations:
- Oversee the management and use of event information to benchmark and track progress to zero avoidable harm.
- Provide analysis and identifying trends from reports (e.g. PSIP data, SHARP report, Service Line Dashboards) to track progress of improvement strategies. Spread and sustain improvement.
- Present informative and actionable patient safety reports to appropriate committees to include high level presentations to Leadership, Medical Executive Committee and Board of Trustees. Include the patient's story of harm.

Risk Management/Claims Activities:
- Work with defense legal counsel to coordinate the investigation, processing and defense of claims against the facility; records, collects, documents, maintains, and provides to defense attorneys any requested information and documents necessary manage facility claims while maintaining privilege of PSWP
- Notify HCI of all actual and potential claims
- Work with security on procedures to reduce the frequency and/or minimize the severity of property loss or assets
- Manage non-HCI cases: accept/process subpoenas, visitor events, property loss or theft, etc.
• Certification in Patient Safety (CPPS) required;
o If not already CPPS, must obtain certification within 12 months of hire.
• Other licenses/certifications required by State
• TeamSTEPPS Master Trainer
o If not already a Master Trainer, must obtain with 12 months of hire.
• Bachelor's Degree in Healthcare related field required. Master's Degree preferred.
• Clinical background required.
• Minimum of three years healthcare experience in patient safety, risk, and/or quality preferred. Healthcare experience should be recent and within a clinical setting such as Hospital, Ambulatory Surgery Center, etc.

A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom

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