Patient Safety Coordinator

University of Maryland Medical System•Towson, MD

3d•Onsite

About The Position

Under limited supervision, ensures organizational compliance with quality measures and other performance indicators required by regulatory and accrediting entities. Provides input into establishing goals, objectives and performance standards. Ensures compliance with policies, quality standards, Joint Commission, CMS and DHMH regulations and codes. Is responsible for the coordination of patient safety activities, and regulatory compliance activities. The position encompasses various roles (e.g., coordinator, educator) and requires effective interpersonal and management skills to motivate staff. In addition, the individual will assist with the management of the UMMC Event Reporting System and will provide support to the Hospital's Performance Improvement Program. Duties include working with UMSJMC departments on risk reduction strategies to enhance patient safety and meet regulatory compliance. Provides the tools, techniques and skills necessary for patient safety, outcomes measurement, process improvement as well as thorough and credible root cause analysis processes. Works with leadership, staff and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate patient safety and improvement activities. Helps develop and revise policies and procedures; interprets and ensures compliance with UMSJMC policies, quality standards, regulations and codes. Develops and maintains interactive and collaborative relationships with key medical staff.

Requirements

BSN is required.
Licensure by the Maryland State Board of Nursing Examiners is required.
Three (3) years nursing experience required.
One to two (1-2) years of progressively responsible professional experience performing quality and/or regulatory compliance review or equivalent is required.

Nice To Haves

Master’s degree preferred.
Current experience in collecting and submitting externally reported quality data is preferred.

Responsibilities

Provides leadership and/or assistance with hospital-wide activities to evaluate and improve adherence to the Joint Commission accreditation standards, CMS Conditions of Participation, and MD State regulations in preparation for all surveys.
Assists with preparation and participates in organizational visits from accrediting agencies.
Participates in survey command center activities which may include but is not limited to: keeping track of and fulfilling surveyor requests for environmental logs, policies and procedures, employee files, contracts, etc., responding to emails and phone calls.
Assists and participates in organization-wide Joint Commission readiness activities including tracers; monitoring and educating staff in regulatory compliance and hospital policy requirements.
Enters tracer data into accreditation tracking tool; reports from these data are provided to staff to use in staff education and improving compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
Assists with internal regulatory assessments to evaluate and validate compliance with current standards set forth by various external regulatory agencies.
Abstracts data to evaluate medical center’s compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
Monitors action plan progress in response to external audits and surveys through concurrent and retrospective chart review.
Works with providers to monitor and promote quality improvement activities related to regulatory requirements and clinical documentation in the medical record.
Participates in Epic UDCs to assure documentation elements are properly embedded in the EHR to meet regulatory standards and conditions of participation.
May assist in State and Federal Quality projects to obtain comparative data on quality and regulatory indicators.
Attends hospital-based committee meetings as assigned.
Assists in the coordination of activities in the journey to become a high reliability organization (HRO).
Coordinates with the Director of Quality & Patient Safety as well as the Patient Safety Officer to direct the patient safety program at UMSJMC.
Coordinates the Quality of Care (QOC) Review Process, including investigations, root cause analysis (RCA), and apparent cause analysis (ACA), and subsequent action plans in accordance with The Joint Commission and State of Maryland COMAR Regulations for sentinel event and adverse event review, reporting and improvement plans.
Partners with UMSJMC leadership to facilitate and prioritize the ongoing focus on a culture of patient safety.
Leads activities to improve event reporting and response to near miss events.
Determines utilization of data to drive improvements in Patient Safety and minimize preventable harm.
Responsible for communication and education regarding patient safety and risk prevention strategies, and ways to achieve and maintain continual regulatory readiness, throughout the hospital and ambulatory setting.
Develops and implements education for employees and medical staff related to patient safety aligning with regulations.
Serves as a consultant and resource person to the unit managers and unit/department clinical representatives (i.e., UPCs) and assists clinical and ancillary departments with the development of clinical and/or patient safety indicators, criteria, and process improvements.
Responsible for the following aspects of the Event Reporting System: Reviewing daily event reports and notifying appropriate managers for follow up, as indicated.
Developing reports to identify patterns and trends.
Tracking trends and anticipating events to reduce preventable harm.
Identifying nominees for monthly Josie King Patient Safety Award.
Identify and investigate patient safety events, opportunities, trends and sentinel events.
Participates in in-service education programs including orientation related to patient safety and the prevention of medical errors and compliance with regulatory (NPSG) standards.
Participates in Proactive Risk Assessments, as required.
Conduct chart reviews for the relevant discipline/program to investigate patient safety and adverse events.
Assists with the implementation of the Safety Culture Assessment survey instrument as determined by the UMMS. Assists with debriefings with individual work areas as results become available and collates action plans.
Shall be a member of or lead key hospital committees and teams as requested for the purpose of ensuring that patient safety and the prevention of medical errors are addressed as needed.
Assists the UMSJMC Patient Safety Officer with reporting to the State and The Joint Commission.
Ensures compliance with external regulators and accrediting agencies (e.g., The Joint Commission, CMS, Maryland State Department of Health Office of Healthcare Quality (OHCQ)).
Ensures that Medical Center and department policies, procedures and standards meet requirements and regulations of regulatory and accrediting agencies related to patient safety.
Travel to all University of Maryland Medical Center locations may be needed.