The Patient Safety Manager (PSM) is a professional Registered Nurse responsible for operating within an established comprehensive Patient Safety Program that complies with all applicable regulations. The PSM serves as a contact point throughout the Captain James A. Lovell Federal Health Care Center (FHCC), North Chicago, Illinois and all the Branch Health Clinics and Community Clinics (formerly known as CBOCs) on patient safety issues. The PSM provides leadership/facilitation to assess, plan, implement, supervise/ coordinate, and evaluate the Patient Safety Program in full compliance with regulatory guidelines. This Patient Safety Manager develops, implements, analyzes, recommends and evaluates various initiatives and activities. Responsibilities include oversight for all patient safety related activities including Root Cause Analysis (RCA) of any event or near miss; and conducting proactive risk assessments, including Healthcare Failure Mode and Effects Analysis (HFMEA). Activities also include investigation, tracking and trending of facility patient event reports, product safety reports/recalls, and other patient safety/risk management related problems. The Patient Safety Program is a vital component to the FHCC's overall Performance Improvement program. Clinical expertise and knowledge of patient safety concepts are essential to ensure compliance with standards established by FHCCVHA/DoD directives. The Patient Safety Assistant helps to support the QM/PI mission of the FHCC. Patient Safety Program data provides a basis for identifying problem areas and opportunities for improvement, and for establishing organization-wide policy instructions and procedures. The PSM analyzes the data and prepares meaningful reports for information, action, or further study by FHCC leadership, committees, teams and other FHCC personnel as appropriate. Major Duties and Responsibilities Coordinates, plans, and implements delegated aspects of the Patient Safety Program. This includes serving as a functional expert and resource person for the FHCC for activities related to the development and monitoring of patient safety- related processes. Assesses actual/potential patient safety issues using a proactive risk control plan to avoid, prevent or limit risk liabilities and/or loss and to stimulate change to avoid medical errors and improve safety. Reviews, investigates, and intervenes on patient event reports, RCA, HFMEA, oral reports, and/or other written documentation that identifies patient safety issues. Provides prompt acknowledgement of reports and timely feedback to relevant personnel and facilitates development of action plans to prevent recurrence. Compiles, maintains, and analyzes data; identifies problem areas or opportunities for improvement through trend analysis and prioritizes areas warranting further evaluation. Initiates actions at the direction of administrative and clinical staff and senior management, intended to improve patient safety. Assists with routine status reports to the leadership. If care/service is determined to be outside of the acceptable standards of care, ensures that follow-up action is taken. Submits information and reports required by directives to senior management, and other authorities as directed by the Patient Safety Supervisor and/or the Chief of QM. Participates in network-wide projects, as assigned, and consults as a member of network Patient Safety Council. Evaluates and prioritizes problem areas. Presents reports to Quality Council, as appropriate, on the status of Patient Safety Program. Performs additional investigations, to include RCA and Healthcare FMEA, as required on issues involving quality of care, risk and patient safety concerns. Plans for personal growth as related to professional goals based on self- assessment, evaluation, and feedback. Assumes responsibility for acquiring knowledge and experience to meet goals. Actively participates in professional organizations. Provides guidance and information on patient safety related topics to providers and staff at the FHCC. Conducts training for professional and paraprofessional personnel within the department and the FHCC. Participates in review preparations conducted by internal and external organizations including, but not limited to, Command Evaluation, VA and Navy Inspector General, Navy Medicine East, Veterans Health Administration, the National Center for Patient Safety, and The Joint Commission Work Schedule: Monday - Friday 8:00am - 4:30pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required