Director of Patient Safety & Regulatory Accreditation

OU Health-posted 3 months ago
Full-time • Senior
Oklahoma City, OK
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Provides strategic leadership for system-wide patient safety and regulatory accreditation programs. Oversees the development, implementation, and monitoring of policies and initiatives that promote a culture of safety and ensure compliance with federal, state, and accreditation standards. Provides strategic leadership for all components of the system-wide Patient Safety program incorporating High Reliability principles and day-to-day leadership and oversight of the Patient Safety department. Advocates for and nurtures a system-wide culture of safety for patients, workforce members, providers, and visitors through direct interaction.

  • Lead the Patient Safety department using High Reliability principles.
  • Oversee event reporting systems and Root Cause Analyses.
  • Facilitate resolutions of adverse events.
  • Promote transparency and continuous improvement in safety practices.
  • Develop and implement compliance strategies aligned with CMS, TJC, and other regulatory bodies.
  • Coordinate accreditation survey activities and readiness efforts.
  • Serve as the official contact for regulatory agencies.
  • Manage regulatory auditing systems and patient tracer activities.
  • Educate staff on regulatory standards and readiness.
  • Responsible for Environment of Care compliance.
  • Serves as Administrator for OUH Regulatory Audit Systems & Patient Safety Platforms.
  • Provides oversight of patient safety adverse events within the system, ensuring transparency in investigations and thoroughness for maximum effectiveness.
  • Promotes High Reliability both within the department, division, and across the system by actively participating in system initiatives driving high reliability.
  • Serves as High Reliability Champion for the system.
  • Responsible for oversight, management, communication of ongoing patient tracer activity.
  • Stays informed regarding new & revised regulatory standards; develops communication and action plans to ensure OUH Regulatory Accreditation Program.
  • Researches and responds to interpretation requests related to regulations and standards.
  • Provides tools to managers, directors, staff and executives for continuous survey readiness.
  • Build and lead high-performing teams in both patient safety and regulatory compliance.
  • Foster collaborative relationships with providers, staff, and leadership.
  • Communicate effectively with senior management and medical staff.
  • Participate in relevant committees and system-wide initiatives.
  • Master's Degree in healthcare related field required.
  • Degree in Nursing preferred.
  • Eight (8) years of Patient Safety, Risk Management, and/or Regulatory Accreditation experience required.
  • Five (5) years of progressive leadership experience required.
  • Certified Professional in Health Care Risk Management (CPHRM) or Certified Professional in Patient Safety (CPPS) required within 12 months of hire.
  • Strong oral/written communication skills with ability to present to staff, physicians, committees and management.
  • Excellent interpersonal and team skills to support and drive initiatives.
  • Demonstrated knowledge of patient safety principles.
  • Proficiency with MS Office products.
  • Demonstrated ability to develop collaborative relationships with key stakeholders within the organization.
  • Strong influence skills.
  • Ability to maintain integrity and trust among leadership and staff.
  • Proven ability to manage a team of professionals and lead a departmental function.
  • Proven ability to solve complex problems effectively and manage multiple high priority deliverables.
  • Demonstrated business acumen.
  • Must be a strategic thinker, self-motivated, and have excellent problem solving and project management skills.
  • Able to work in a challenging, varied, and fast paced environment with multiple high priority deliverables.
  • Ability to analyze, assemble, prepare, and present data at all levels throughout the organization.
  • Knowledge of federal, state, and local regulatory standards related to healthcare such as The Joint Commission and Centers for Medicare and Medicaid Services.
  • PTO
  • 401(k)
  • medical and dental plans
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