Director of Patient Safety & Regulatory Accreditation

General Description: 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.

Essential Responsibilities:

Responsibilities listed in this section are core to the position.Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• 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.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: Master's Degree in healthcare related field required. Degree in Nursing preferred.

Experience: Eight (8) years of Patient Safety, Risk Management, and/or Regulatory Accreditation experience required. Five (5) years of progressive leadership experience required.

License(s)/Certification(s)/Registration(s) Required: Certified Professional in Health Care Risk Management (CPHRM) issued by the American Society for Health Care Risk Management (ASHRM) or Certified Professional in Patient Safety (CPPS) issued by the Institute for Healthcare Improvement (IHI) required within 12 months of hire.

Knowledge, Skills and Abilities:

• 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.

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