This role manages aspects of Quality, Safety, Performance Improvement, Risk Management, and Patient Experience and the Infection Control Program at Penn Highlands Clearfield. This director assures Penn Highlands Clearfield is in compliance with the standards of all regulatory entities. This role seeks to improve patient care by developing quality improvement programs and consistent practices as well by measuring and reporting relevant information. The Director will align initiatives to the PHH system’s strategic visions and culture. The position will also serves as the Patient Safety Officer.
*Complies with PENN HIGHLANDS CLEARFIELD policies and procedures, accreditation agency requirements, and federal, state or local law and regulations
As Patient Safety Officer, maintains a comprehensive Patient Safety Program in accordance with the federal and state requirements.
a) Coordinate the implementation and refinement of the patient safety program goals, policies, procedures, and strategies.
b) Coordinate and prioritize the activities of the patient safety improvement and management committee.
c) Oversee and coordinate the investigation of serious/sentinel events. Conducts RCAs and FMEAs as needed. Coordinates the development and completion of resulting action plans.
d) Ensure compliance with sentinel event, serious event, incident, and infrastructure failure reporting requirements as mandated by the law/regulations.
e) Ensure the disclosure of serious events to patients and/or families is carried out in accordance with organizational policy and law/regulations.
f) Conducts patient safety rounds, and develops and implements actions to address findings.
g) Provides regularly scheduled reports/dashboards to the appropriate committees and PH management
h) Ensures the appropriate safety projects and priorities are identified on an ongoing basis, and that organizational resources are assigned appropriately to achieve performance goals across the organization.
i) Trains new personnel on patient safety processes, and provides ongoing education and support to existing staff according to their patient safety duties and responsibilities.
Maintains a comprehensive Quality and Risk Management Program in accordance with the federal and state requirements, in collaboration with system Rish Management.
a) Develops and oversees the risk management program goals, policies, procedures, and the implementation of strategies.
b) Ensures organizational adherence to federal and state risk management requirements.
c) Researches, designs and implements specific risk management related programs throughout the organization.
d) Works with department managers to monitor and evaluate risk management activities, and assists in implementing changes in policies to address findings.
e) Records, collects, documents, maintains, and provides to hospital attorneys any requested information and documents necessary to prepare testimony in pending litigation. This includes coordinating responses to interrogatories, attending depositions on behalf of the hospital, and providing for acceptance of Subpoenas, Summons, complaints in Trespass, etc.
f) Coordinates the preparation of staff that may be called as witnesses at trails and depositions.
g) Responds to crisis situations that have risk management implications and assist all hospital and medical staff with problem solving
h) Establishes and maintains links between the risk management functions related to the clinical aspects of patient care and safety and quality assurance functions
i) Ensures the appropriate risk management projects and priorities are identified on an ongoing basis, and that organizational resources are assigned appropriately to achieve performance goals across the organization.
j) Administers all hospital liability insurance and serves as liaison with hospital’s liability carrier.
Coordinates the patient grievance processes.
a) Coordinates the patient grievance process, logging and sending acknowledgements of grievance receipt, tracking investigation completion, and ensuring second level reviews.
b) Ensures the completion of all complaints meets grievance and HIPAA regulatory standards.
c) Reviews patient complaints that may be the source of legal actions, and initiates acceptable solutions while the patient is in the hospital if possible
d) Communicates patient grievances with Patient Safety Committee at least monthly.
e) Participates in staff orientation and education related to the patient satisfaction survey and complaint processes.
Leads hospital’s Patient Excellence and Initiative programs and develops and directs programs and plans to improve patient experiences.
a) Coordinates the hospital’s patient experience survey process (HCAHPS).
b) Communicates patient experience survey results organization-wide.
c) Provides training to staff on culture of services and align with the PHH service, culture, vision of strategy.
*Infection Control Duties and responsibilities
Responsible for developing the implementation and assessment of the Infection Control program
Performs Clinical Surveillance Rounds
Coordinates with PHD infection control for on-site surveillance of infection control issues
Maintain knowledge of infection control regulations and reporting requirements
Development of New Staff by participating in New Employee Orientation
* Performance Improvement Related Duties and Responsibilities:
Participates in the development, implementation, and evaluation of department goals, objectives, and policies.
Assist with the development and documentation of performance improvement activities in all departments of the hospital.
Coordinates performance improvement activities across the hospital and facilitates reporting.
General duties as directed.
A Bachelor's Degree in Nursing required. PA Registered Nurse licensure or certification is required.
Minimum of 3 years’ experience in quality, safety or Performance Improvement required. Experience managing and coordinating functions requiring a working knowledge of hospital policies and procedures, as well as governmental regulations. Prior risk management or insurance experience preferred.
Demonstrated ability to coordinate functions and work with teams.
Excellent verbal and written communication skills.
Effective presentation and teaching skills.
Lean certified. Performance Improvement knowledge and experience with PA DOH rules and regulations.