Job Summary This position provides consultation to appropriate local and network leaders, physicians and staff to reduce the risk of harm to patients and improve clinical outcomes. Provides ongoing evaluation of performance, facilitates prioritization of improvement activities, and shares knowledge as subject matter expert. Develops and implements innovative strategies to improve patient safety, quality of work, quality of care, and clinical quality outcomes. Serves as portal of entry to the quality department and ensure successful implementation of initiatives at the local level.
Provides ongoing assessment of performance and clinical outcome data to identify improvement opportunities and/or trends. Collaborates with stakeholders to identify and validate optimal sources of data to support safety, quality, and performance improvement initiatives. Aggregates and summarizes data including use of statistical techniques. Identifies opportunities for improvement in process, structure and/or outcome.
Provides project management by leading project activities related to Quality and Safety. Coordinates project activities including RCAs, process Improvements projects, timelines, information gathering, and tracking of project issues. Coordinates activity of all staff and tasks associated with assigned projects. Establishes multi-disciplinary project teams to ensure active participation of Quality and appropriate department personnel. Conducts periodic project status meetings and provides periodic status reports.
Analyzes patient safety events and near misses to identify trends. Reviews and screens events to identify cases for evaluation by the Sentinel Event/Serious Safety Event Determination Team. Facilitates root-cause analyses in conjunction with appropriate others. Tracks and ensures timely follow up on root cause analysis action plans and communicate lessons learned.
Acts as a facilitator and change agent toward building a just culture and a culture of patient safety. Assists leaders in development of tactics to address opportunities identified from culture of safety surveys. Supports implementation of patient safety walk rounds. Educates staff on National Patient Safety Goals, National Quality Forum/Leapfrog Safe Practices. Monitors compliance with these goals and work with appropriate stakeholders to ensure compliance.
Facility-based Patient Safety Consultants: Attend and support facility based huddles. Prepare senior leaders for Hospital Performance Improvement Review and assist with populating the dashboard. In collaboration with clinical quality consultants, assist with preparation of countermeasures and action plans in response to identified opportunities for improvement. Attend/support to hospital and/or medical staff committees as needed. Ambulatory Patient Safety Consultant: Evaluate performance on standardized measures such as those in the Healthcare Effectiveness Data and Information Set (HEDIS). Perform clinical chart review to investigate outliers in collaboration with others such as the Infection Preventionist. Evaluate the effectiveness of specific interventions. Support leaders in summarizing and disseminating experience-related learning
Evaluates compliance with standardized processes to assigned setting which may include, but not limited to: such as bedside handoffs, VTE prophylaxis and transitions of care. Performs clinical chart review (concurrently and/or retrospectively) to investigate outliers (e.g., AHRQ Patient Safety Indicators, mortality, readmission) in collaboration with team members including case manager, clinical specialty-based quality consultant and Infection Preventionist, and Nursing-Patient Outcomes Coordinator. Evaluates the effectiveness of specific interventions.
If appropriate, educates and oversees Safety Coaches in collaboration with Network Director of Patient Safety. Serves as an expert on patient safety best practices, human factors, and continuous quality improvement.
Assists in preparation of educational strategies to meet identified needs. Ensures standardized approach to teamwork education in collaboration with Network Director of Patient Safety. Educates leaders and staff on the collection, analysis and utilization of data and best practices.
Performs internal audits as part of the Internal Audit process.
Assists with Rapid Process Improvement and/or Failure Mode Effects Analysis activities or lead specific local clinical process improvement or implementation teams or supports state, regulatory and accreditation activities.
Supports implementation of evidence based best clinical practices. Conduct and present research to identify best benchmarking opportunities. Support integration and standardization of processes across the organization.
Performs other duties as assigned or requested.
Internal Number: 2018-7236
Let’s transform healthcare together.
Every day, we bring patients convenient, coordinated access to healthcare while providing meaningful service to our community.
Join us and you will:
Develop professionally and achieve your career goals
Enrich your life with a focus on wellness
Enjoy a compassionate, caring culture with outreach to our local communities
Support the well-being of you and your family with a diverse portfolio of benefits
Welcome to HonorHealth.
We are a non-profit, local healthcare organization known for community service and outstanding medical quality. Our organization encompasses five acute care hospitals with approximately 10,500 employees and 3,100 volunteers, urgent care centers, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.