Summary:

Responsible for the enterprise-wide patient safety plan. Responsible to eliminate or reduce the
incidence and severity of harm/loss to patients, families, staff, and the organization. Responsible for
the Beta HEART program. Coordinates the Reliability Management Team. As the Health System Patient
Safety Officer, emphasis is on achieving highly reliable health care through a commitment to the goal
of zero harm; promoting a safety culture, which ensures employees are comfortable reporting errors
without fear of retaliation; incorporating highly effective process improvement tools and
methodologies into our work flows; and ensuring that everyone is accountable for safety and quality.

Essential Duties & Responsibilities:

• Coordinates the Reliability Management Team (RMT) including meetings and identified initiatives.
• Develops, monitors and reports activities to improve patient safety, focusing on National Quality
Forum (NQF) Safe Practices, Hospital Acquired Condition (HAC)s, and Institute for Healthcare
Improvement (IHI) and Agency for Healthcare Research and Quality (AHRQ) indicators.
• Responsible for patient safety standards in the applicable accreditation survey, state licensure
regulations, and federal conditions of participation.
• Serves as a patient safety and High Reliability organization subject matter expert. Functions as
process improvement team leader/member to reduce hospital acquired conditions, injuries, errors,
and unintended outcomes. This expertise is provided in various venues as appropriate or assigned.
• Assists the Risk Manager with the TFHD Event Reporting system, including review of safety,
behavioral, and disruptive events by staff and providers. Provides operational guidance and training to
all staff. Monitors and escalates issues to appropriate Director/Manager and other members of the
leadership team.
• Identifies and implements patient safety best practice initiatives by reviewing sentinel event alerts,
Patient Safety Organization information, and other key organizations and references. Participates in
event analysis and case reviews.
• Coordinates the BETA HEART® (healing, empathy, accountability, resolution and trust) program,
which creates a reliable, sustainable, and transparent culture of safety. This includes the annual
culture of safety SCORE survey. Compiles survey results, conducts debriefings, and assists with
identifying plans for improvement with the Director/Manager/Supervisor of each department.
• Reviews care and treatment provided by staff and providers as part of the peer review or other
event analysis processes.
• Assists with regulatory compliance, accreditation and state survey process, through staff education
and survey preparedness rounds.
• Leads process improvement activities, utilizing Lean/Six Sigma principles, with director/managers
and Medical Staff to improve patient safety.
• Recommends appropriate revisions to new or existing policies related to areas of expertise.
• Maintains and updates the Patient Safety quality dashboard.
• Participates in Environment of Care rounds and routinely conducts safety rounding. Provides survey
round recommendations to the director/manager and assists with process improvement and staff
education as needed.
• Conducts Failure Modes and Effects Analysis (FMEA) as new or revised processes are developed.
• As assigned, works under the direction of the Director of Quality & Regulations to investigate events,
conduct research, or other relevant activities associated with the department.
• Prepares and submits summary reports of Patient Safety activities to the Performance Improvement
Committee, Medical Staff Quality Committee, Board Quality Committee, and Board of Directors as
assigned.
• Represents the department on appropriate committees as assigned.
• Ensures compliance with Healthcare Facilities Accreditation Program (HFAP), Centers for Medicare &
Medicaid Services (CMS) and all other federal, state and regulatory agencies.
• Maintains a clean and safe working environment.
• Demonstrates System Values in performance and behavior.
• Complies with System policies and procedures.
• Other duties as may be assigned.

Minimum Education/Experience:

Bachelor's degree AND 5 or more years of relevant experience

Required Licenses/Certifications:

• Master's Degree preferred
• Lean Six Sigma preferred
• Certified Professional in Patient Safety preferred or acquired within six months of hire

California RN license upon hire

Other Experience/Qualifications:

• Strong technical knowledge and an understanding of data elements and data analysis
• Strong analytical and problem solving skills and a strong attention to detail
• Ability to produce analysis of basic quality measure reporting.
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• Ability to converse knowledgably with physicians
• Preferred:
• Master’s degree
• Certified Professional in Patient Safety (CPPS) certification
• Green belt or lean certification
• Knowledge of EPIC electronic health record