General Summary

Under limited supervision, analyzes patient safety events and works with hospital leadership, clinical teams, and the Department of Risk Management to drive institutional change toward high reliability, zero harm and Just Culture. This role serves as a vital resource for the patient safety program, departmental leaders, physician colleagues, unit dyads, and front-line team members. Partners with leadership to facilitate and prioritize the ongoing focus on a culture of patient safety. Assists with developing and revising policies and procedures and is responsible for interpreting and ensuring compliance with organizational policies, quality and safety standards, and external regulations and codes (i.e., OHCQ, TJC, and Maryland COMAR).

Duties and Responsibilities

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 of activities in the journey to become a High Reliability Organization (HRO) with the focus on zero harm. Identifies, measures, monitors, and evaluates safety improvement activities within the organization in the context of a Just Culture.
2. Identifies and investigate patient safety events, opportunities, trends, and sentinel events.
3. Coordinates with the Manager of Patient Safety/(PSO) and senior leadership to direct the safety program. This includes:

• Coordinates the Root Cause Analysis (RCA) Process. This involves conducting investigations, facilitating root cause analysis (RCA) meetings, and running apparent cause analyses (ACA) when appropriate.
• Develops action plans in accordance with The Office of Healthcare Quality (OHCQ) and the Joint Commission (TJC) regulations for sentinel event and adverse event review, reporting, and improvement plans. Facilitates action plan creation, completion, and sustainment monitoring.

1. The "investigation" portion of adverse events and RCAs includes conducting chart reviews for the relevant discipline/program and preparing patient safety event summaries/timelines necessary for informed, collaborative discussion and problem solving.

• Coordinates, improves, and provides leadership in the development of effective working relationships.
• Fosters and maintains interactive and collaborative relationships with key medical staff (including Chairs and Chiefs) and provides guidance to clinical, departmental, and operational leadership to ensure key patient safety-centered care metrics are monitored and performance improvement is consistent with departmental objectives.

• Collaborates with leaders in safety, quality, performance improvement, and data management to determine optimal utilization of data to drive improvements in Patient Safety and minimize preventable harm.

1. Works as part of the patient safety team to identify and lead activities to improve event reporting and response to near miss events. Supports project management for identified patient safety projects discovered through event reports, adverse events, or data trends.
2. 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.
3. Collects and analyzes data, develops presentations, provides consultation, and leads service-specific and hospital-wide committees.
4. Develops and implements education for employees and medical staff related to patient safety, the prevention of medical errors, and compliance with regulatory (NPSG) standards. Participates in staff orientation and contributes to the organizational Safety Newsletter, safety alerts, "Lessons Learned" and Great Catch Awards program.
5. Serves as a consultant and resource person to the unit managers and unit/department clinical representatives. Assists clinical and ancillary departments with the development of clinical and/or safety indicators, criteria, and process improvements.
6. With the guidance of the Manager/PSO, is responsible for the for the following aspects of the Event Reporting System:
7. 1. Reviewing daily event reports and notifying appropriate managers for follow up, as indicated
   2. Developing reports to identify patterns and trends
   3. Tracking trends and anticipating events to reduce preventable harm
   4. Identifying nominees for monthly Great Catch award

1. Participates in Proactive Risk Assessments/FMEAs/Common Cause Analysis, as required.
2. 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.
3. Shall be a member of or lead key hospital committees and teams as requested for the purpose of ensuring that safety and the prevention of medical errors are addressed as needed.
4. Educating leaders and clinical staff on how to establish a blameless and supportive environment that balances and non-punitive response to human error with the appropriate level of accountability for reckless behavior.