In order to fill our Mission of serving our community by helping each person achieve optimal health and well-being by providing compassionate, exceptional, and affordable healthcare services, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Excellence, Integrity, Team, and Innovation. All employees must regard themselves as an ‘owner’ of Genesis and keep our patients at the center of everything we do - always.
Work Shift:
Scheduled Weekly Hours:
40Department:
Quality ManagementOverview of Position:
The Patient Safety Consultant is responsible for the management of the hospital’s incident/event reporting system, including staff and managers’ education and for conducting intensive investigation or root cause analysis related to the delivery of safe and efficient patient care. This role is responsible for facilitating management follow-ups and assuring for comprehensiveness of corrective actions. This position works collaboratively with the Risk Management/Legal Department, Nursing Quality, Quality Patient Experience & Service Excellence Department, and other affected department staff to investigate significant and sentinel events and to coordinate the root cause analysis process.ESSENTIAL DUTIES
1. Manages the occurrence/event reporting system across the organization and ensures the integrity of data.
2. Routinely monitors all elements of the occurrence/event reporting systems software, including system dictionaries, user securities, software updates, and interface data transaction and reports.
3. Analyzes, summarizes, and reports on patient safety activity to hospital and clinic management.
4. Develops and maintains an ongoing mechanism for monitoring action plans and deficiencies and a proactive process for areas at risk with monthly reporting to the hospital’s committee structure.
5. Develops mechanisms for communication of patient safety related information across the hospital and clinics
6. Disseminates information regarding and promotes use of “best practices” and process improvements in patient safety.
7. Provides staff and management education on use of the incident reporting system. Actively promotes the use of the organization’s incident reporting system by physicians, nurses, and other healthcare providers for reporting adverse patient events. Designs and implements ongoing in-service educational presentations that facilitate the understanding and implementation of patient safety standards within the hospital and clinics.
8. Provides staff and management training on the use of the incident reporting system, both one-to-one, Just-In-Time, and scheduled for large groups.
9. Recommends specific actions to eliminate or mitigate the risk of patient harm.
10. Responds to queries for event entry from management, assists with EPIC risk management tools,
11. Review all patient incident/event reports and conducts investigations in cooperation with the Risk Management/Legal Department for reported events and patient safety issues, including medical record reviews, interviews, equipment investigations, and reporting to external agencies. Participates in and leads the review of significant adverse events to gain an understanding of the processes for RCAs.
12. Establishes processes to ensure that comprehensive review of events is timely, and that information is sufficient for hospital leadership to make a determination regarding regulatory reporting.
13. Reviews all patient safety and environment of care standards. Conducts analyses to include trend, pattern, and other statistically valid techniques to assist in focusing program attention and efforts. Makes recommendations based on findings.
14. Serves as a resource for patient care departments and clinics on issues of patient safety and provides patient safety consultation for inquires from physicians, nurses, and other healthcare practitioners.
15. Serve as chairperson for the Patient Safety Team weekly meetings and administratively assists in preparation for and management of this meeting.
16. Serve as a member of the HRO meetings and administratively assists with preparation and implementation of this meeting.
17. Serve as a member of the accreditation regulatory within the Quality Patient Experience and Service Excellence department.
18. Accurately determines rate of compliance and assists with meeting target benchmarks.
19. Evaluates compliance with CMS Standards and other regulatory and accrediting bodies, conducts compliance monitoring and actively participates in accreditation surveys.
20. Performs initial review of physician/staff complaints regarding patient care issues.
21. Reviews charts for Patient Safety and generic screenings, mortality reviews, surgical case reviews, infections, transfer case reviews, and potential litigation reviews.
22. Assists with development and reviews policies and procedures for patient safety.
23. Performs root cause analysis and assists with development of action plans
24. Provide education to physicians and other hospital staff to help guide them on process/outcome improvements.
25. Reviews physician peer review/medical staff cases and prepares for committee presentation.
26. Attends and presents cases at the Physician Peer Review Committee.
27. Supports Nursing Peer Review Committee and assists with case presentations for review.
28. Responsible for oversight of all incident reports and assures data entry is complete and prepare reports.
29. Assists the Patient Experience Department with patient care issues related to care or lost items.
30. Makes department/unit rounds to address patient safety and risk issues.
31. Maintains updated knowledge of current standards related to CDC, HFAP, CMS, etc.
32. Oversees a variety of projects assigned by the manager/director and performs other functions as assigned.
33. Always maintains the highest level of professionalism and confidentiality.
34. Develops and improves personal and departmental knowledge of computer software and reporting functions.
QUALIFICATIONS
1. Bachelor’s degree in a health-related field and current Ohio RN License required
2. Three (3) years previous experience in performance improvement activities, risk management, quality management, or patient safety.
3. In depth knowledge and understanding of local, state, and federal rules and requirements related to responsibilities.
4. Excellent interpersonal, decision-making, analytical facilitation, conflict resolution and investigative skills.
5. Demonstrated excellence with listening and verbal and written communication skills.
6. Ability to manage multiple projects independently and use critical thinking skills.
7. Ability to work independently and under pressure in a complex and changing working environment.
8. Excellent computer skills and knowledge of computer software, including programs such as Word, Excel, PowerPoint, etc.
PATIENT CENTERED CARE & BEHAVIORAL EXPECTATIONS
1. Living the Genesis Mission, Vision and Values
• Performs work in a manner that is quality focused.
• Treats patients, co-workers, visitors and volunteers with courtesy, compassion, , and respect.
• Results oriented and focused on achievement of objectives.
• Acknowledges and responds to the diversity of people and the situation.
• Encourages peers (others) to be owners of change.
• Always makes the effort to anticipate and exceed customer needs and expectations.
• Possesses the ability to engage others with patience and understanding.
• Acts in a manner that creates positive first and lasting impressions.
• Demonstrates the ability to own issues until they are resolved.
2. Patient Centered
• Introduces self and role…connects with everyone.
• Communicates effectively (i.e. advising others of actions, pertinent information, time durations, etc.) and asks for feedback.
• Asks for and anticipates needs and concerns of others.
• Maintains a positive work environment for staff and a healing environment for patients (i.e. safe, clean, quiet, etc.)
• Maintains the dignity and privacy of each person; manages confidential/sensitive information appropriately.
• Responds to requests in an appropriate and timely manner.
• Exits patient/customer encounters courteously, asking if there are additional needs that can be addressed.
3. Promotes Patient and Employee Safety
• Demonstrates safe Patient Handling (i.e. transfers, transport, care administration, nutrition, medication, etc.)
• Demonstrates safe Materials Handling (i.e. appropriate use and disposal of chemicals, infectious wastes, etc.)
• Demonstrates appropriate knowledge of Infectious Disease precautions and use of proper protective equipment
• Demonstrates Slips/Trips and Falls Awareness.
• Actively contributes to maintaining a safe, clean and quiet environment.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential function of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Works in an office environment.
2. Answers telephone calls, uses personal computer and other business machines extensively, which requires the ability to apply finger dexterity. Individual bends, reaches and pulls file drawers to file records and reports.
3. Regularly lift or move up to 10 pounds, frequently lift or move up to 25 pounds and occasionally lift or move up to 50 pounds.
4. Vision abilities required include up close vision, peripheral vision, depth perception and the ability to adjust focus.
This description reflects in general terms the type and level of work performed. It is not intended to be all-inclusive, nor portray the specific duties of any one incumbent.
Thank you for your interest in employment at Genesis. Genesis is committed to being an equal opportunity employer. Selection of applicants for employment is based only on qualifications and the requirements of a specific job.