Associate Director, Peer Rev Quality Svc Pt Safety (Onsite)

Cedars-Sinai•Los Angeles, CA

6d•$160,638 - $281,112•Onsite

About The Position

The Associate Director, Patient Safety has overall responsibility for managing the Patient Safety Program in partnership with the Chief Patient Safety Officer. The role develops and implements the patient safety plan and medication safety strategies, including programs, processes, education, and communication across the Medical Center. It serves as a resource to senior executive management, Medical Staff, Nursing, and other Hospital and Health System personnel on patient safety and medication safety matters and activities. The position manages patient and medication safety activities, coordinates efforts across departments and stakeholders, and provides consultation to medical staff and management on integrating safety into daily work. It develops and updates safety plans and measurable objectives; leads safety education; supports adverse-event review and follow-up; and advances continuous quality improvement, data quality, case screening, peer review coordination, and a culture of safety. The role also oversees incident reporting, supports legal and regulatory compliance, maintains policies and procedures, and assists with departmental operational and capital equipment budgets.

Requirements

Bachelor's degree in Nursing.
Five years of hospital-wide experience with The Joint Commission standards.
Eight years of experience in an acute care complex setting in quality improvement, management, or nursing education/position.
Two years of experience leading quality and service improvement activities and achieving outcomes corresponding to customer expectations.
Certified Professional in Patient Safety (CHPQ) within 1 1/2 years of hire.

Nice To Haves

Master's degree in MPH, MHA, MBA, or MSN.
Certified Professional in Healthcare Quality (CPPS) within 1 1/2 years of hire.

Responsibilities

Co-facilitate the Executive Safety Group with senior leadership to establish priorities and organize initiatives to prevent first events, eliminate repeat events, and develop and maintain a culture of safety.
Manage and oversee the Patient Safety Program and patient and medication safety activities; coordinate efforts with departments and stakeholders and consult with medical staff and management on incorporating safety into daily work.
Create, manage, and annually update the Patient Safety Plan; develop measurable objectives consistent with organizational goals and timelines; and communicate patient safety goals and relevant information to executive and medical staff leadership.
Develop and conduct patient safety and medication safety education for employees, medical staff, nursing staff, senior executives, and other organizational members, including orientation and continuing education programs.
Integrate learning across Significant Adverse Event and Medication Safety Programs into the Patient Safety Program; collaborate with information technology on a patient safety learning center and website; and disseminate current safety knowledge and practices.
Prepare agendas and support medical staff leadership for the Sentinel Adverse Event Review Committee; manage Significant Adverse Event, Root Cause Analysis, Sentinel Event Alert, and SAE Peer Review follow-up processes.
Develop operationally focused Executive Safety Group meeting agendas and participate in pre-meetings with operational executives and clinical leaders to review and build consensus on safety initiatives and follow-up actions.
Develop, implement, monitor, and champion performance improvement processes and policies addressing key patient safety issues, applying Continuous Quality Improvement principles.
Monitor, benchmark, trend, and report patient safety indicator performance and develop and maintain a Patient Safety Dashboard.
Manage peer review case screening, including case capture, clinical screening, technology use, pattern and trend identification, worksheet preparation, peer review materials, accurate and timely MIDAS data entry, and maintenance of established timelines and volumes.
Collaborate with the Peer Review Department on case investigations involving a peer review component as directed by the Chief Patient Safety Officer and Medical Directors of Medical Affairs.
Plan, coordinate, and assist with implementation of the biennial Culture of Safety Survey with Organizational Development and clinical and operational leaders; identify opportunities and develop action plans.
Manage the incident reporting system for Cedars-Sinai Medical Center, Marina Del Rey Hospital, and Medical Network; oversee data integrity and quality assurance, provide routine reporting, and maintain related policies and procedures.
Establish and maintain systems for compliance with legal and regulatory standards, hospital policies, and procedures; serve as a resource on The Joint Commission, California Department of Public Health, and Title 22 requirements relating to patient and medication safety.
Develop, maintain, and implement current policies and procedures and maintain a policy and procedure manual.
Assist with preparation and control of the department's operational and capital equipment budgets.