Clinical Patient Safety Program Management (30%)

Responsible for planning, developing, and implementing a clinically based program designed to provide high-quality, safe inpatient and outpatient healthcare under the Military Health System Patient Safety Program.

Program Administration

• Ensures successful implementation and sustainment of the Patient Safety Program.
• Develops and approves local operating procedures and policies.
• Identifies healthcare process risks and recommends improvements.
• Acknowledges Patient Safety Reports and provides timely staff feedback.
• Evaluates occurrence reports and determines the required level of review.

Sentinel Events and Root Cause Analysis

• Directs, facilitates, and oversees Sentinel Event investigations.
• Ensures:
  • Comprehensive data collection
  • Credible Root Cause Analyses
  • Development of action plans
  • Required reporting through appropriate channels
• Ensures Patient Safety Action Plans are:
  • Implemented
  • Evaluated
  • Communicated to appropriate organizations
• Functions as the primary Root Cause Analysis coordinator.
• Ensures lessons learned are distributed throughout the Military Health System.

Performance Monitoring

• Establishes administrative controls ensuring recommendations are implemented.
• Recommends corrective actions and independently implements resolutions when appropriate.
• Provides routine updates and ad hoc reports.
• Provides staff feedback regarding lessons learned.
• Determines event classifications and required assessments.
• Verifies action plans and evaluates organization-wide impact.
• Tracks corrective actions in accordance with Joint Commission standards.
• Uses quantitative and qualitative measures to evaluate intervention effectiveness.

Risk Assessment

• Collaborates with:
  • Quality Management
  • Risk Management
  • Chief of Medical Staff
• Coordinates Medical Incident Investigations.
• Facilitates:
  • Proactive Risk Assessments
  • Failure Mode Effects Analyses (FMEA)
• Tracks outcomes and reports results to leadership.

Data Analysis

• Reviews Potentially Compensable Event cases.
• Utilizes Patient Safety Reporting systems and analytical tools.
• Identifies causal factors and recommends corrective actions.
• Educates staff on use of Patient Safety Reporting systems.
• Oversees routing and closure of Patient Safety Reports.
• Collects, trends, analyzes, and presents patient safety data.
• Disseminates information to appropriate committees and leadership.
• Accesses committee minutes, medical records, and medical staff files as required.

Accreditation and Compliance (15%)

Directs and coordinates Patient Safety Program accreditation and compliance activities.

Responsibilities include:

• Advising staff on accreditation requirements.
• Researching and interpreting:
  • Accrediting agency standards
  • DoD policy
  • Air Force policy
• Preparing the organization for:
  • Staff Education Visits
  • Inspections
  • Accreditation surveys
• Coordinating implementation of Joint Commission National Patient Safety Goals.
• Monitoring compliance and sustainment of corrective actions.
• Collaborating with:
  • Risk Management
  • Quality Management
  • Credentialing and Privileging
  • DHA partners
• Conducting annual program appraisals.
• Performing gap analyses.
• Maintaining required records.
• Supporting Congressional inquiries, Inspector General complaints, and Freedom of Information Act requests.

Education, Culture of Safety, and Strategic Planning (10%)

Establishes mechanisms to educate staff on patient safety principles and foster a culture of safety.

Responsibilities include:

• Guiding leadership safety rounds.
• Developing comprehensive patient safety education programs.
• Coordinating:
  • New employee orientation
  • In-service education
  • Team training
  • Individual consultations
• Educating staff regarding:
  • Patient Safety Program requirements
  • Risk identification
  • Risk assessment
  • Risk control
• Coaching staff in High Reliability Organization principles.
• Delivering initial and annual refresher training.
• Tracking training requirements using DHA-approved learning management systems.
• Maintaining continuity files.
• Supporting strategic planning efforts.
• Advising leadership on:
  • Patient safety policies
  • Healthcare planning
  • Regulatory requirements
• Recommending patient safety initiatives for strategic planning.
• Supporting internal review systems to ensure compliance with accreditation and regulatory requirements.

Supervision (10%)

Supervises the Patient Safety Assistant Coordinator assigned to the Medical Treatment Facility.

Responsibilities include:

• Determining work priorities.
• Assigning and reviewing work.
• Developing work schedules.
• Instructing employees on work methods.
• Monitoring employee performance.
• Reviewing position descriptions.
• Identifying training needs.
• Developing employee training plans.
• Providing cross-training opportunities.
• Informing employees of organizational policies.
• Managing attendance and leave.
• Resolving informal complaints.
• Interviewing and selecting subordinate employees.
• Developing performance plans.
• Conducting counseling sessions and evaluations.
• Promoting Equal Employment Opportunity and other special emphasis programs.