General Summary

Under limited supervision, analyzes patient safety events, and communicates with hospital leadership, clinical teams and Risk Management drive institutional change toward high reliability and zero harm. Provides leadership and direction to multi-disciplinary teams (which include physicians and senior leaders) to collaboratively accomplish patient safety and safety improvement strategies at UMMC.

The position encompasses various roles (e.g., coordinator, educator, project manager and facilitator) and requires effective interpersonal and management skills. A deep understanding of clinical care and clinical leadership is integral to gaining credibility and collaboration from colleagues. Duties include working with UMMC departments and MMCIP (risk management) on risk reduction strategies to enhance patient safety in the context of Just Culture. This role works with leadership, staff and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate patient safety and improvement activities. Reviews patient records and prepares patient safety event summaries and timelines necessary for informed, collaborative discussion and problem solving Helps develop and revise policies and procedures; interprets and ensures compliance with UMMC policies, quality standards, regulations and codes. Manages reports to regulatory agencies, including the Joint Commission and Office of Healthcare Quality. Develops and maintains interactive and collaborative relationships with key medical staff. Serves as a vital patient safety resource to clinical teams and support staff including faculty, unit dyads and front-line team members.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Assists in the coordination and implementation of activities in the journey to become a high reliability organization with the focus on zero harm.

2. Coordinates with leadership to direct the patient safety program

A. Coordinates root cause analysis (RCA) and follow up action plans in accordance with The Joint Commission and State of Maryland COMAR Regulations for sentinel event and adverse event review, reporting and improvement plans. Facilitates action plan creation and completion.

B. Partners with UMMC leadership to facilitate, prioritize and advance the ongoing focus on a culture of patient safety.

C. Leads activities to improve event reporting and response to near miss events.

D. Determines utilization of data to drive improvements in Patient Safety and minimize preventable harm.

E. Responsible for communication and education regarding patient safety and risk prevention strategies throughout the hospital and ambulatory setting.

F. Develops and implements education for employees and medical staff related to patient safety. Publish monthly Lessons Learned for nursing staff and 60 Seconds of Safety for providers as well as other educational documents such as CPUs and Safety Flashes.

G. Serves as a consultant and resource person to unit managers and unit/department clinical representatives and assists clinical and ancillary departments with the development of clinical and/or patient safety indicators, criteria, and process improvements.

H. Responsible for the following aspects of the Event Reporting System:

• Reviewing daily event reports and notifying appropriate managers for follow up, as indicated and escalates to leadership when needed.
• Developing reports to identify patterns and trends
• Tracking trends and anticipating events to reduce preventable harm
• Identifying nominees for monthly Great Catch awards

I. Identifies and investigates patient safety events, opportunities, trends and sentinel events

J. Participates in in-service education programs including orientation related to patient safety and the prevention of medical errors and compliance with regulatory (NPSG) standards.

K. Participates in Proactive Risk Assessments, as required.

L. Conducts chart reviews and interviews to inform RCA discussion for the relevant discipline/program to investigate patient safety and adverse events

M. Assists with the implementation of the Safety Culture Assessment survey instrument as determined by UMMS. Assists with debriefings with individual work areas as results become available and collates action plans.

N. Shall be a member of or lead key hospital committees and teams as requested for the purpose of ensuring that patient safety and the prevention of medical errors are addressed as needed.

O. Assists the UMMC Patient Safety Officer with reporting to the State and The Joint Commission.

P. Ensures compliance with regulatory requirements related to Patient Safety. Ensures compliance with external regulators and accrediting agencies (e.g., The Joint Commission, CMS, Maryland State Department of Health Office of Healthcare Quality (OHCQ). Ensures that Medical Center and department policies, procedures and standards meet requirements and regulations of regulatory and accrediting agencies related to patient safety.