PATIENT SAFETY ACCREDITATION COORDINATOR

EXEMPT

Salary: $110,000-$118,000 (Commensurate with experience)

POSITION SUMMARY:

The Patient Safety Accreditation Coordinator (PSAC) has oversight of the patient safety/facility-wide patient risk compliance programs and accreditation and survey readiness. In this leadership role, the PSAC directs others within the facility towards process improvements that will support the reduction of medical/health care risks and other factors that contribute to unintended adverse patient outcomes and conduct safety assessments. This PSAC educates other hospital staff on the system-based causes for medical error/risks, consults with management and staff, and communicates literature- based ideas regarding effective patient safety and risk reduction strategies to others within the organization.

 

This position also provides leadership and monitors compliance with all regulatory standards. This includes education, planning, and conducting systematic, ongoing individual patient tracers as well as formal and informal system/ process tracers to assess and provide feedback, education, and consultation on Joint Commission/CMS standards compliance to all entities within the organization. This person assumes responsibility and accountability for the duties of the position and is cognizant of the philosophy, standards, objectives, and policies of the Governor Juan Luis Hospital and Medical Center and their respective department.

 

POSITION RESPONSIBILITIES/DUTIES:

1.       Monitors quality of patient care and/or ensures compliance with professional standards, Virgin Islands licensure practices, Joint Commission standards, JFL standards and other clinical benchmarks.

2.       Collaborates with organizational leadership to assure activities necessary to evaluate JFL’s compliance with the Joint Commission Sentinel Events Alerts and Root Cause Analysis, and CMS conditions of participation.

3.       Develops and demonstrates comprehensive technical knowledge of departmental and organizational systems and policies.

4.       Serves as a liaison between the CEO, Senior Leadership, and the Safety Committee as designated.

5.       Oversee the management and use of medical error information. Reviews internal error reports and utilize information from external reporting programs.

6.       Collaboratively investigates patient safety issues within the facility. Participate in root cause analysis of internal error reports.

7.       Recommends and facilitates changes within the organization to improve patient safety, based on identified risks.

8.       Conducts monthly departmental rounds to assess patient safety/risks, actual and potential opportunities.

9.       Collaborates the development of policy and procedures affecting organizational safety.

10.   Serve as a resource for clinical departments on issues of patient safety.

11.   Support and encourage error reporting throughout the organization through a non-punitive error reporting system.

12.   Support the development of a recognition program aimed at improving patient safety.

13.   Collect and trend patient safety data for dashboard reporting.

14.   Organizes, leads, and implements tracer methodology for standards of compliance: Joint Commission, CMS, and other regulatory bodies. Coordinates and schedules mock tracers throughout the organization at regular intervals and provides timely post tracer written reports.

15.   Reviews and analyzes pertinent performance improvement data, Joint Commission and CMS standards, elements of performance and conditions of participation.

16.   Collaborates with the Director of Facilities/designee, Infection Control Coordinator, Medical Staff, Nursing Leadership and Department Heads to ensure compliance to Joint Commission and CMS standards and elements of performance and continued survey readiness.

17.   Seeks opportunities for professional/career growth/development.

 

REQUIRED QUALIFICATIONS (Please List Education/Experience/Credentials:

Must have successfully completed an accredited school of nursing; BSN with minimum of 5 years clinical.

experience required. Master’s degree preferred. Prior supervisory experience preferred. Prior experience in

accreditation/regulatory affairs/performance improvement/patient safety in healthcare preferred. Knowledge of

risk management principles and issues regarding patient safety and regulatory requirements.

 

REQUIRED KNOWLEDGE/SKILLS/ABILITIES:

Current RN licensure in the Virgin Islands; Current American Heart Association (AHA) or American Red Cross Professional Rescuer BLS certification. Must be knowledgeable and proficient in working with computers and on a computer program such as Microsoft Excel, Word, and PowerPoint. Must function independently, have flexibility, personal integrity, and the ability to collaborate effectively with patients, personnel, and support agencies. Ability to develop policies and procedures. Must possess strong analytical skills.