Program Manager- Patient Safety and Regulatory

Christiana Care Health System - Newark, DE (30+ days ago)4.1


PRIMARY FUNCTION:
To manager and design the ambulatory Patient and Employee Safety Program in collaboration with CCHS Patient Safety Officer and delegates, and to support compliance with all regulatory standards including OSHA, TJC, and CMS. Work efforts will be consistent with the organizational Performance Improvement Plan and be constructed/designed to support MGCC with strategic design to allow for expansion and applicability to Christiana Care Quality Partners (CCQP) populations. Provides leadership and consultative services to office practices and ambulatory support structures within the organization in achieving best practices for patient safety and regulatory compliance.

PRINCIPAL DUTIES AND RESPONSIBILITIES:
Facilitates and motivates personnel and leadership from throughout the ambulatory structure to determine current and best practice for patient and employee safety.
Maintains a current knowledge of TJC, CMS, OSHA, DE state law and other regulatory standards as related to safety.
Assists leadership and other system wide customers in interpretation and application of TJC National Patient Safety Goals.
Incorporates PI/CM processes through the management of patient safety teams including project planning, analysis, development, oversight and implementation.
Develops and establishes ambulatory procedures and processes to improve patient safety and for regulatory requirements as needed to align the organizational policies.
Serves as a mediator when personal, political or fragmented issues impede progress.
Maintains a collaborative professional working relationship with clinicians and administrative staffs necessary to develop, implement, and evaluate successful patient safety processes of care.
Facilitates and motivates personnel and leadership from throughout the system to implement evidenced and consensus based patient safety processes of care.
Develops implementation plans that provide clear time lines and accountability.
Assists in educational initiatives related to the implementation of new care processes.
Disseminates information and assesses ambulatory services compliance related to the National Patient Safety Goals, Sentinel Event Alerts and recommendations, and AHRQ/NQF best practices as directed by Patient Safety Committee.
Supports physician leadership in the development and presentation of annual safety reports, and other patient safety sub-projects as needed.
Oversees adverse patient safety event process.
Guides patient safety teams in the analysis of process and outcome improvements related to patient safety.
Develops and maintains plans for monitoring, tracking, evaluating and improving patient safety practices.
Monitors results against targets in the evaluation of effectiveness of new processes and includes clinical and process outcomes.
Presents progress reports/findings on a regular basis to appropriate constituencies within the system.
Identifies opportunities for improvement and alternate strategies when goals are not met.
Enhances the understanding of patient safety practices through interactions with physicians, administrative staff, staff and other members of the healthcare team.
Develops communication strategies to disseminate and communicate new patient safety processes of care.
Actively participates in system wide management activities, attends meetings and in-service/educational programs, and other activities as requested.
Maintains required credentials; assume responsibility for ongoing professional growth; exhibit a high level of professionalism; act as role model for staff and others in the organization.
Maintains confidentiality of patient/members and staff information.
Serves as a consultant to teams, practitioners, departments and leaders in understanding the National Patient Safety Goals and other safety practices.
Identifies annual professional goals and evaluates achievement of them.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:
Daily contact with the Program Director- Quality and PI- MGCC/CCQP.
Frequent contact with key leadership within MGCC, CCQP, Value Institute, Accreditation Services, Medical Dental Staff Services, Organizational Education, and Informatics.
Periodic work efforts with leadership within Organizational Excellence
Periodic contact with Case/Peer Review Staff

DIRECTION/SUPERVISION OF OTHERS:
Clinical Regulatory Coordinator

DIRECTION/SUPERVISION RECEIVED:
Reports directly to the Program Director for Quality and Performance Improvement- The Medical Group and CCQP

EDUCATION AND EXPERIENCE REQUIREMENTS:
Bachelor's degree in nursing or related healthcare field required.Master's degree preferred.
Licensed to practice nursing in state of DE, minimum of five years of clinical experience, including one year work experience in patient safety, research, or quality.
Certification by National Association for Health Care Quality (CPHQ), or required within one year of hire.
Supervisory and leadership experience required.
Organizational skills and project management experience required.
Education, understanding of and/or experience in one or more of the following are desirable: information technology, performance improvement, clinical pathways/guidelines, adverse event management Root Cause Analysis & Failure Mode Effect Analysis, outcome analysis, utilization management, team facilitation and education (patient/staff).

Christiana Hospital, Newark, Delaware. This 1,007-bed, 1.3-million-square-foot modern facility provides a level of care only available in large-scale teaching hospitals. Christiana Hospital includes Delaware's only Level-I Trauma center (as verified by the American College of Surgeons), which is prepared to handle the most extreme medical emergencies. In fact, it is the only Level-I Trauma center on the East Coast corridor between Baltimore and Philadelphia. Christiana Hospital has also been nationally recognized in U.S. News and World Report's Best Regional Hospitals rankings as #1 in Delaware and #3 in the Philadelphia metro area, plus High Performing in 9 Adult Procedures/Conditions. Academic medical center, Baltimore area, Best regional hospital, Community-based medicine, Community health, Clinician, Delaware hospital, Delaware's largest health system, Electronic medical records, Epic EMRs, Everest Award-winner, In-patient, Level I Trauma Center, Magnet® designation, Nationally recognized, Outpatient, Philadelphia area, Provider, Surgery center, Teaching hospital, Wellness, Wilmington, Newark, U.S. New & World Report ranking, Expert, Serve, Care, Healthcare, Respectful, Dover, Bear, Middletown, Rehoboth Beach, Bethany Beach, Delmarva Peninsula, New Castle, Elkton, Maryland, Glasgow, Hockessin, Brookside, Smyrna, Pike Creek Valley, Milford, Claymont, Pike Creek, Wilmington Manor, North Star, Seaford, Southeastern Pennsylvania, Southern New Jersey, Vineland, Millville, West Chester, Kennett Square, Swedesboro, Carneys Point, Woodstown, Salem, Elmer, Deptford Township, Washington Township, Pitman, Glassboro, Franklin