Patient Safety & Regulatory Director
Patient Safety and Regulatory Director
Serves as the lead for the accreditation and licensure for Howard University Hospital with direct responsibility for compliance with the National Patient Safety Goals. The position will also serve as the Patient Safety Officer for Howard University Hospital. This role provides leadership for safety assessments, coordinates the activities of the patient safety committee, educates faculty and staff on the system-based causes for medical errors, consults with management and staff, and communicates literature-based ideas regarding effective patient safety strategies to others within the organization.
As the lead for accreditation and licensure for Howard University Hospital, the incumbent will coordinate with the areas that have specific accreditation/certification requirements, including, but not limited to, the American College of Surgeons, College of American Pathologists, American Association of Blood Banks and such agencies/organizations/bodies as assigned.
NATURE AND SCOPE:
Interacts with management, staff physicians, and other healthcare providers, Hospital and University officials, and accrediting and licensing agencies, as appropriate.
Oversees the creation, review and refinement of the accreditation/licensure activities of the organization on a continual basis.
Directs others within the organization toward process improvements that will support the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes.
Manages compliance activities for The Joint Commission accreditation, the DC Department of Health licensing, and other accrediting/licensing bodies.
Coordinates activities of the Regulatory Committee, provides leadership for accreditation/licensing readiness, educates others on regulatory compliance, consults with management and staff, and communicates effective strategies for regulatory preparedness.
DEPARTMENT: Quality Improvement REPORTS TO: Sr. Director, Quality
Coordinates the activities of the Regulatory Committee.
Oversees the management of organizational readiness for accrediting/licensing agencies visits. Reviews and utilizes information from regulatory/licensing organizations (e.g. TJC Perspectives, DC Department of Health notices, etc.).
Investigates accrediting/licensing issues within HUH. Coordinates and participates in Tracers with appropriate departmental and administrative leadership.
Recommends and facilitates change within the organization to improve accreditation/licensing readiness, based upon risk assessment.
Collaborates in the development of policies and procedures affecting organizational accrediting/licensing
Develops a mechanism for internal communication of accreditation!licensure information.
Designs and implements educational presentations that facilitate the understanding and implementation of accreditation/licensure requirements.
Serves as a resource for clinical departments on issues accreditation and licensure.
Reports to the Quality Management Committee and the Sr. Director for Quality and Process Improvement the existence of known accreditation and licensure non-compliance within the facility, as well as actions taken. Identifies barriers to the corrective action.
Maintains ongoing readiness for site inspections.
Oversees the creation, review and refinement of the scope of the Patient Safety Program on an annual basis.
Coordinates the activities of the Patient Safety Committee.
Oversees the management and use of medical error information. Reviews adverse event reports in the
Patient Safety Network (PSN) and utilizes information from external reporting programs (e.g. ECRI
Health Device Alerts).
Investigates with Risk Management patient safety issues in the facility. Prepares, coordinates and participates in Root Cause Analyses.
Recommends and facilitates change within the organization to improve patient safety, based upon identified risks.
Collaborates in the development of policies and procedures affecting organizational safety. Develops a mechanism for internal communication of patient safety related information.
Designs and implements educational presentations that facilitate the understanding and implementation of patient safety standards.
Serves as a resource for clinical departments on issues of patient safety.
Supports and encourages non-punitive error reporting throughout the organization through the Patient Safety Network.
Reports to the Quality Management Committee and the Sr. Director for Quality and Process Improvement on the occurrence of known medical and health care errors and identified near misses and dangerous conditions within the facility, as well as actions taken, either proactively or based upon occurrences. Barriers to the implementation of safety programs shall be addressed as well.
Keeps current on core competencies.
Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
Participates in activities that promote adherence to federal healthcare program requirements.
Actively participates in Health Sciences Compliance Program activities.
Adheres to the requirements of the HIPAA Privacy Policies and Procedures.
Maintains confidentiality of patients, families, and staff.
Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
Knowledge of and training in Patient Safety.
Ability to understand safety, regulatory and licensure rules and regulations.
Knowledge of statistical data analysis and principles of research.
Knowledge of medical terminology.
Ability to communicate effectively with senior management about areas of vulnerability in safety, accreditation and licensure.
Ability to train others effectively.
Ability to work in a consultative and advisory capacity with managers and senior management.
Ability to develop and maintain collaborative, collegial relationships with managers in all areas.
Ability to teach in a dynamic environment.
Ability to work well independently.
Working knowledge of Microsoft Office Suite, including Visio and Access, e-mail and personal computers.
Ability to maintain patient confidentiality and show respect for privacy.
Ability to handle issues of a confidential nature.
Competence in both oral and written English.
Ability to establish and maintain effective and harmonious work relationships with staff, physicians, hospital and university officials, and the general public.
Masters Degree in Nursing, Patient Safety or other healthcare discipline, or equivalent experience and training.
Certified Patient Safety Officer, preferred.
Black Belt in Lean Six Sigma, preferred.
Current District of Columbia license for profession, if appropriate.
Must be able to stand, walk, sit, climb, balance, stoop, kneel, crouch, crawl, bend, pull, push, dig, reach, handle, write, type, file, speak, hear, see (depth perception & color vision), calculate, compare, edit, evaluate, interpret and organize for extended periods of time.
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