Patient Safety and Regulatory Manager

General Summary/basic PURPOSE OF JOB:In this role, the Patient Safety and Regulatory Manager is responsible for the development, implementation, and continuous improvement of regulatory, performance improvement and patient safety initiatives for all hospitals and clinics within Sinai Health System. This individual provides oversight for system-wide performance improvement and patient safety and regulatory projects that meet national standards and have publicly reported outcomes. This individual leads strategies to promote a culture of quality and patient safety throughout Sinai Health System. This individual develops, directs, and facilitates hospital wide care transformation activities and programs (clinical, operational and service line) aimed to improve patient care, create an extraordinary patient and caregiver experience, enhance and strengthen the culture of safety and quality within the system, ensure continued survey readiness, and to make operations more efficient and cost effective.Reporting Relationships: Reports to: System Director, Regulatory &Patient Relation and Patient Safety (Patient Safety Officer) Provides Supervision to: NoneESSENTIAL FUNCTIONS AND DUTIESCultivates a culture of patient safety in the healthcare environment by promoting safe practices, nurturing the just culture of patient safety, and improvement processes that detect, mitigate or prevent harm.Manages hospital wide patient concerns/grievances documentation in compliance with CMS guidelines and hospital policy.Convenes, participates in rounding initiatives to improve the patient/family experience, reduce adverse events, and raise employee satisfaction and loyalty. Leads service/process/operations improvement efforts to improve the patient, family and guest experience demonstrating improved outcomes on experience measures (i.e. HCAHPS, EDCAHPS, etc.). Continuously assesses patient safety culture and opportunities to strengthen and enhance the safety culture within the organization and the populations it serves. Applies safety science principles and methods in order to achieve high reliability practice. Identifies, reports, and addresses safety risks and events in the assigned areas to enhance the safety practice across the organization. Conducts all event related causal analyses for the site. Works collaboratively with the service line outcomes and performance managers for processes that are fully contained within the service line. Collaborates with all caregivers to analyze patient safety practice, events, and systems and continuously improves the systems of care in the assigned area in the journey toward high reliability. Responsible for the management of the Occurrence Reporting System; routinely summarizes and reports data from the system; identifies trends and patterns. Functions as Hospital liaison to external patient safety-related database entities. Conducts Apparent Cause Analysis, Root Cause Analysis, and coordinates with Department Chairs, the Medical Staff Department in event related Focused Professional Practice Reviews. Coordinates SHS participation in external Patient Safety programs such as the PSO and other projects. Leads performance and process improvement, project management, and change management activities to support operational and clinical quality initiatives. Deploys and masters improvement initiatives to lead the Sinai Health System to a High Reliability Organization with 5 Star Rating. Identifies and works to improve transparency enabling the removal of barriers that impede or prevent implementation of performance improvement initiatives.Creates and participates in a system-wide training program for leaders and front line staff through teaching, coaching and reinforcing Continuous Improvement High Reliability concepts. Deploys and masters standard performance improvement methods including lean, six sigma, failure mode effect analysis, causal analysis, plan/do/check/act (PDCA) and/or other improvement tools. Provides highly consistent and collaborative project management of improvements that cross the service lines for the site, and in collaboration with system leadership to ensure standardization of best practices. Leads change management through mastery of change management practices, tools, and communication skills. Leverages the organization’s analytic environment to help guide data driven decision making and inform quality improvement activities. Develops, implements, and applies the procedures for the governance of data assets, changes to the EMR, and analytic principles across the organization. Designs, implements, and improves data collection plans related to key performance areas. Generates reports and analyses to support related quality improvement, patient safety and operational effectiveness using key statistical tools, including but not limited to, run charts, bar charts, pie charts, control charts, pareto charts and cause and effect diagrams.Analyzes data and identifies key findings and develops action plans. Presents complex data with simplicity of design in a clear, easy to understand format. Collaborates on multidisciplinary teams and provides analytical support for various projects related to patient safety and regulatory as appropriate. Interprets, explains and discusses data analysis results. Leads survey readiness activities that support continuous compliance with accreditation and governmental regulations, including voluntary, mandatory and contractual reporting requirements.Develops, deploys and leads the chapter lead model for regulatory readiness for the site. Develops, deploys and executes the survey response process to ensure a dynamic and extraordinary positive experience for surveyors presenting to survey the organization and the site leaders and frontline staff and providers being surveyed. Participates in support role during any on-site survey activity. Leads the evaluation, monitoring, and improvement of compliance with internal and external quality indicators and requirements. Develops, files, and executes plans of correction in follow up to surveys.Maintains “expert” knowledge of standards related to accreditation and regulatory bodies; i.e., The Joint Commission, CMS, IDPH, CARF, and HFAP. Serves as the hospital’s expert on Tracer Tool content and rules for documentation; develops and implements mechanisms to educate and update on a timely basis, all responsible administrative and clinical leaders when revisions occur. MINIMUM Education:

Bachelors in Nursing (BSN) or Master's degree in health related field required

MINIMUM WORK EXPERIENCE:

3-5 years of previous job-related experience

Quality/Performance Improvement, Regulatory and Patient safety/Patient Relation experience preferred

KNOWLEDGE & SKILLS:

Strong communication, interpersonal, organizational and facilitation skills.

Demonstrated knowledge of quality improvement principles and practices (i.e., rapid cycle improvement, Six Sigma, Lean, balanced scorecards, etc.), project management, patient safety concepts, data analysis, data management and statistical process control in healthcare.

Proficient computer skills with extensive experience using various software application such as MS Excel, Word, Access, PowerPoint; relational database structures and reporting software.

Experience with clinical/healthcare software applications preferred; demonstrated knowledge and skills in statistical packages and concepts including control charts.

High-level analytic skill in the use of complex quality data in business/value development and the display of findings is desired.

Excellent oral, written, “platform” and interpersonal communication skills.

Ability to work independently.

High degree of creativity in problem-solving.

REQUIRED LICENSES, Certificates, Registrations:

Green belt or black belt in Lean and/or Six Sigma Certified preferred

Professional in Healthcare Quality (CPHQ) preferred

C PPS or IHI Patient Safety Executive Graduate required within 1 year