Patient Safety Specialist

Overview

The Patient Safety Specialist (PSS) responds to patient safety issues brought to the Office of Quality & Patient Safety (OQPS) through a number of routes or sources. Activity surrounding the identified issue is commensurate with the nature and severity of the issue, with increasing responsiveness based on the urgency and seriousness of the patient safety concern. Critical thinking and clinical expertise is applied throughout the process of working with an accredited organization in responding to patient safety concerns. A collaborative approach, mindful of the patient experience, the healthcare provider or organization experience, and of other stakeholders (e.g. government agencies), is essential. Most interactions on these issues are held with executive leadership of the healthcare organization, such as the Chief Executive, Chief Nursing Officer, Chief Medical Officer, or immediate designees.

Responsibilities

• Responds to reports of quality of care concerns and safety risks regarding the Joint Commission accredited healthcare organizations related to our standards of care and the impact or potential impact on a patient(s). Consults with other subject matter experts as needed.
• Triages the report in accordance with OQPS procedures, Medicare Requirements, and sentinel event policy and takes follow up action accordingly. Assimilates other known information about that healthcare organization for issues of the greatest urgency and makes recommendations to senior leadership regarding the need for on-site survey activity or other actions as appropriate.
• Facilitates for-cause survey activity. Ensures that resulting on-site survey activity is scheduled through the scheduling unit to occur within the defined timeframe in accordance with the regulatory requirements. Collaborates with Accreditation Operations, Legal Operations, Standard Interpretation Group and others across the enterprise as necessary and participates in pre, mid & post survey calls as requested by the field director and/or OQPS management.
• Initiates interaction with the healthcare organization when the information suggests the incident meets sentinel event definition, to confirm reviewability and to determine the method by which the organization will complete and submit their comprehensive analysis i.e. root cause analysis or other analysis tools.
• Upon submission of the RCA, provides feedback and guidance to the accredited organization’s leadership (either through conference call, web discussion or face to face dialogue), to establish that a thorough and credible RCA has been completed, and ensures that improvement plans are related to the causal factors, and that measurements are in place to ensure a sustainable implementation plan.
• For adverse events not meeting the sentinel event definition, works with the organization through the ‘organization response’ process, to evaluate their response to the safety concerns, to assess the organization’s current status in terms of standards compliance, and to identify whether or not the response is substantive and factual and thus, acceptable to bring reports to closure.
• For issues which are at a priority level that do not require the activities described above, those issues are tracked and monitored for trends to inform future analyses.
• Completes appropriate documentation for above actions for each incident while maintaining the confidentiality of the data in accordance with applicable Joint Commission Corporate data governance policy.
• For issues which have reached a point of completion, provides follow-up with the complainant in a sensitive manner, sharing information as allowed by the Public Information Policy in order to provide closure.
• Responds to data requests in a timely manner providing correct background to frame the data accurately, and to be in accord with the Public Information Policy for both internal and external requests.
• Collaborates with Legal Affairs and Compliance on issues related to confidentiality, retaliation concerns and other legal issues in the clinical setting.
• Effectively communicates with internal and external customers in a respectful, constructive and collegial style consistently providing excellent customer service.
• Provides education to healthcare organizations or others about Joint Commission’s process for responding to sentinel events, safety events, and for-cause surveys. Utilizes OQPS data to identify opportunities to assist organizations with identifying proactive and sustainable risk reduction strategies as they respond to safety risks.
• Serves as a role model in the support of and implementation of enterprise, division and departmental mission and initiatives utilizing RPI tools and strategies as indicated. Leads and/or participates in internal project work groups to identify and implement improvements to our internal processes.
• Engages in training or educational sessions for various customer groups at the national level or on a custom basis and c ontributes to various Joint Commission publications drawing from the OQPS aggregate data and the safety event experiences

Qualifications

• Healthcare clinician with a master’s degree. Certified Patient Safety Specialist (CPPS) preferred. If not CPPS, achievement within one year of hire.
• A minimum of five to seven years recent clinical experience providing direct patient care. Management experience preferred.
• Experience in quality improvement, risk management, or patient safety preferred.
• Experience in data management, statistics, or LEAN/Six Sigma preferred, in order to assimilate information and to recognize trends and vulnerabilities in processes.
• Demonstrated ability to empathize with the experience of patients and their families.
• Demonstrated ability to interact with the executive leadership of an accredited organization about serious patient safety risks.
• Demonstrated excellent customer relationship management skills.
• Interpersonal skills to interact effectively with individuals at various levels both inside and outside of the organization, often in sensitive situations.
• Demonstrated analytic, coaching and diplomatic skills.
• Strong writing and speaking skills.
• Knowledge of Joint Commission sentinel event alerts, survey process, standards, national performance goals and requirements preferred.
• Demonstrated ability to function well in a fast-paced, challenging environment and within a team.
• Strong computer skills preferred including word processing, databases and spreadsheets