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

Cedars-Sinai Medical Center•Los Angeles, CA

5d•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. This role develops and implements the patient safety plan and medication safety strategies, including programs, processes, education, and communication across the Medical Center. The Associate Director 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. The role co-facilitates the Executive Safety Group and manages patient and medication safety activities, plans, education, event reviews, peer review screening, incident reporting, continuous quality improvement, data quality, compliance, policies and procedures, and departmental fiscal responsibilities. It works with operational executives, clinical leaders, medical staff, and other departments to identify risks, prevent repeat events, promote a culture of safety, and support measurable improvements.

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) certification within 1½ years of hire.

Nice To Haves

Master’s degree in MPH, MHA, MBA, or MSN.
Certified Professional in Healthcare Quality (CPPS) certification within 1½ years of hire.

Responsibilities

Co-facilitate the Executive Safety Group to establish priorities and organize initiatives that prevent first events, eliminate repeat events, and develop and maintain a culture of safety.
Manage and oversee patient and medication safety activities, coordinating efforts with departments and stakeholders and advising medical staff and management on applying safety concepts in daily work.
Create, manage, and annually update the Patient Safety Plan; develop measurable objectives aligned with organizational goals and timelines; and communicate patient safety goals and information to executive and medical staff leadership.
Develop and deliver patient and medication safety education for executive management, medical staff, nursing staff, and other employees, including orientation and continuing education.
Integrate learning from Significant Adverse Event and Medication Safety Programs into the Patient Safety Program and design a patient safety learning center, including a website, in collaboration with information technology.
Stay current with patient safety knowledge and science, and coordinate its dissemination and application within the organization.
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 Executive Safety Group meeting content with an operational focus; participate in pre-meetings with operational executives and clinical leaders to review rationale, build consensus, and support follow-up actions and safety initiatives.
Develop, implement, monitor, and champion performance improvement processes and policies relating to key patient safety issues, applying Continuous Quality Improvement principles.
Monitor, benchmark, trend, and report patient safety indicator performance; develop and maintain a Patient Safety Dashboard.
Manage peer review case screening, including case capture, clinical screening, technology use, trend identification, worksheet generation, preparation of review materials, accurate and timely MIDAS data entry, and maintenance of established timeframes 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 the biennial Culture of Safety Survey in collaboration with Organizational Development, and work with clinical and operational leaders to 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 and hospital policies and procedures; serve as a resource on The Joint Commission, California Department of Public Health, and Title 22 patient and medication safety requirements.
Develop, maintain, and implement current policies and procedures and maintain a policy manual.
Assist with preparation and control of the department’s operational and capital equipment budgets.