Clinical Quality and Patient Safety Manager

The Patient Safety and Clinical Quality Program Manager provides leadership and direction for the patient

safety and clinical risk managment programs as well as the clinical quality program (focused on the central

quality assurance team of OHSUs quality management department). They work with OHSU Healthcare leadership to develop and implement a strategic Patient Safety Plan. TheProgram Manager works with others within the facility towards a systematic implementation of effectivepractices designed to reduce error create reliable systems identify improvement opportunities mitiate riskand improve patient outcomes. They educate clinical and hospital staff on system-based design and error prevention provide safetyconsultation to management and staff disseminates best practices and safety information to others and actsas a change agent to implement effective patient safety strategies within the organization. They maintain expertise regarding and make recommendations to improve the OHSU Management System (OMS) reporting infrastructure to improve effectiveness and empowerment sustaining a just and safe culture. They apply expertise to drive quality improvement and serve as an advisor and contributor in the development and execution of OHSU Quality Management strategy and the overall system quality goals. The Program Manager oversees the administration of our periodic Culture of Safety Survey and coordinatesthe subsequent action plans

Safety Program Leadership

• Provides leadership to OHSU Healthcare on activities that promote patient safety.
• Oversees the design and implementation of the Patient Safety Program including the annual review and revision of the Patient Safety Plan.
• Annually evaluates the effectiveness of the Patient Safety Program.
• Promotes a culture of safety through education specific improvement activities and periodic evaluation and assessment.
• Co-chairs the Safety Oversight Committee and works closely with the Quality Management Director and the OMS committees to provide therequired oversight.
• Directs the work and provides supervision of the Patient Safety Specialists and the Patient Safety Analyst.
• Provides clinical risk management/patient safety leadership in assessing the safety of new equipment and technology clinical risk management and medication safety by organizing/staffing the Patient Safety Review Committee and being a member of the Medication Safety Committee Culture of Safety Oversight Committee Infection Prevention & Control Committee and the Value Analysis Committee.
• Serves as the organizational liaison to the Oregon Patient Safety Commission and our Patient Safety Organization.
• Provides leadership with our event reporting system Datix Patient Safety Intelligence (PSI). Assures the review of submittals; assures timely investigation and response; identifies critical events for further analysis/action; assures timely aggregate reporting; and uses the PSI data o identify trends and areas for improvement.
• Provides leadership in the use of patient safety/risk management toolswithin the organization including case reviews and critical analysis toolssuch as Root Cause Analysis (RCA) and Failure Mode Effects CriticalityAnalysis (FMECA).
• Coordinates and assures timely completion of root cause analyses and action plans for all sentinel events.
• Works with senior leadership nursing the Professional Board and other clinical departments to implement promote and maintain a just culture.
• Maintains a positive collaborative and accountable relationship with the various OHSU departments including Quality Management MedicalAffairs Regulatory Affairs Infection Control Risk Management NursingClinical Departments Pharmacy and Patient Advocate/Patient Relations.

Clinical Quality Program Management: Directs and leads the operationalmanagement of the clinical quality program of OHSU Quality Management.

• Designs and maintains Clinical Quality Program function and structure to assure that organizational quality assurance and connection to quality improvement accomplishes strategic quality goals.
• Directs the central quality assurance team resources to align and address quality priorities and integrate quality management at critical points in the organizational infrastructure.
• Works with key quality leaders in healthcare services and academic departments to support and drive healthcare quality and safety priorities highly matrixed environment
• Examines and addresses systems and structural barriers to achieving performance goals.
• Inspires leads and is adept at unleashing the talents of those they work with.
• Demonstrates inclusiveness collaboration and the ability to connect multi-disciplinary teams across sites and leaders in different levels of units of care.
• Leads resourcefully and applies stewardship principles
• Fosters individual growth and contribution to the larger mission of the department and institution.
• Collaborates actively with quality medical staff leadership and leaders critical and support services on quality assurance and improvement initiatives.

Patient Safety Program Implementation

• Recommends and facilitates change within the organization to improve patient safety based on identified risk and recommendations frominternal and external sources.
• Communicates patient safety-related information within the organization including the Administrative Team the OHSU Management System (viaSafety Oversight Committee) the Professional Board and the UHS Board.
• Develops reviews and revises policies and procedures related to patient safety/clinical risk management.
• Coordinates and assures the organizations compliance with regulatory safety requirements.
• Works closely with the Patient Safety Review Committee CMO CNE Director of Quality Management to evaluate and review all seriouspatient safety events.
• Reports to the appropriate oversighte bodies the root cause analyses action plans and progress with action plan completion for all sentinelevents.
• Works with the Risk Management and the Patient Advocate Office in investigating reviewing and performing follow-up work on all potentiallycompensable events (PCEs).
• Collaborates with other departments to achieve a coordinated effort in responding to medical device recalls alerts and mandatory reporting ofadverse events involving equipment and supplies.

Other Duties as Assigned

• Masters degree or higher in health-related field or equivalent experience and training.
• Three to five years of patient safety quality management or clinical risk management experience.
• Three to five years of inpatient and/or ambulatory clinical experience.
• Previous leadership management or program management experience

Job Related Knowledge Skillsand Abilities (Competencies):

• Knowledge of risk management principles and methods related to patient safety.
• Knowledge and skills in root cause analysis robust system design and FMECA
• Knowledge and skills in human factors and error prevention strategies and design.
• Knowledge and skills in change management.
• Knowledge and skills in the use of performance improvement tools and techniques.
• Knowledge understanding and skills in data collection analysis and display.
• Knowledge of healthcare rules and regulations.
• Evidence of excellent verbal and written communication skills.
• Ability to work with a high degree of independence.
• Management principles tools and techniques with proven program leadership skills in large scale performance improvement projects
• Knows how to build highly functioning teams
• Knows how to inspire and lead in a highly matrixed environment
• Models integrity respect teamwork
• Understands strategic planning
• Exceptional verbal and written communication skills
• Creates effective/efficient systems and processes
• Decision making consistent with fiscal stewardship principles

• Experience in implementation of system changes across a complex organization
• Certified Professional in Healthcare Quality or Licensed clinical professional

Generally 8-5 M-F work schedule but hours fluctuate significantly depending on need and may include weekends andvariable shift hours. Possible weekend call coverage for clinical risk management.