Patient Safety Manager

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Department:

Quality Management

The Patient Safety Manager is a pivotal role in advancing a culture of safety and excellence within the hospital. Responsible for the designs/redesigns, implementation and evaluation of the Salinas Valley Heath Medical Center’s Patient Safety Program. This position focuses on implementing Just Culture principles, promoting High Reliability Organization practices, and managing patient safety incidents and follow up action plans, and ensuring compliance with CMS Patient Safety Structural Measure requirements. The Patient Safety Manager collaborates across departments to proactively identify processes that need improvement, implement corrective actions, and foster an environment where safety is a shared priority. The Patient Safety Manager is responsible for the direction and leadership of the culture of safety and delivery of safe and highly reliable care at Salinas Valley Health Medical Center. Responsible for the Patient Safety Program in collaboration with the Patient Safety Officer. The manager reports to the Director of Quality and Patient Safety and works closely with the SVHMC stakeholders and leadership.

1. Just Culture and High Reliability Practices

• Lead the sustainment of a Just Culture framework to promote transparency, accountability, and learning from incidents.
• Support leadership and staff in integrating High Reliability Organization principles into daily operations to enhance system safety and reliability.
• Develop and deliver educational programs to promote safety awareness and Just Culture principles across all levels of the organization.
• Designs/redesigns, implements, evaluates and collaboratively maintains the Salinas Valley Heath Medical Center’s Patient Safety Program

2. Patient Safety Data and Patient Safety Incident Management

• Oversee the reporting, investigation, and resolution of patient safety incidents using the RLDatix system.
• Conduct safety incident debriefs, root cause analyses and action planning (RCA2) and Failure Mode and Effects Analyses (FMEAs) to identify contributing factors and implement corrective action plans. Ensures that success measures are implemented, tracked and sustained in collaboration with unit and department leaders.
• Monitor trends and develop actionable insights from incident data to mitigate risks and improve outcomes.
• Collaborate with multidisciplinary teams to ensure timely and effective response to adverse events.

3. CMS Patient Safety Structural Measure Compliance

• Ensure hospital compliance with the Centers for Medicare & Medicaid Services (CMS) Patient Safety Structural Measure requirements.
• Coordinate data collection, analysis, and reporting to demonstrate performance in patient safety domains.
• Partner with Quality Improvement teams to address gaps and sustain compliance with regulatory standards.

4. Data-Driven Decision Making, Reporting, and Performance Improvement

• Prepare and present reports on patient safety performance, trends, and program outcomes to leadership and relevant committees. Maintains the patient safety measures for the Board Dashboard and other unit and department initiatives.
• Collects, monitors, analyzes, and reports patient safety incident data and makes recommendations for performance improvement. Leads patient safety performance improvement initiatives.
• Collaborates with the Director of Quality and Patient Safety to establish and track key performance indicators (KPIs) for patient safety.
• Manages the yearly Leapfrog survey reporting by supervision and collection of data, create action plans for new measure and for sustainment of the scores.
• Monitors organizational patient safety activities using the National Patient Safety Goals as defined by the Joint Commission.
• Appropriately follows up on reported events, using the Patient Safety Debrief Tool, conducts interviews, local surveys, audits, and facilitates problem solving and process improvement.

5. Leadership and Collaboration

• Serve as a subject matter expert on patient safety and a resource for staff, leadership, and external stakeholders.
• Acts as a liaison between the hospital and external regulatory agencies regarding patient safety matters.
• Builds strong interdisciplinary relationships to foster collaboration and shared accountability for safety outcomes.
• In collaboration with human resources department plans and leads annual patient safety culture assessments and action plans.
• Collaborates with operational leaders on the implementation of evidence-based practices for improved patient safety culture.
• Utilizes current evidence-based literature and research on organizational reliability and patient safety science in daily practice.
• Demonstrates excellent group management skills, including the ability to facilitate stakeholders through conflict and toward mutually agreeable solutions.
• Uses advanced clinical knowledge/judgment to promote staff involvement in planning, decision-making and evaluating outcomes, contributes to organizational success as they improve patient care systems.
• Acts as a resource for practice standards and oversight body requirements.
• Provides expert leadership and facilitation of TEAMSTEPPS 3.0
• Co-chairs the Safety and Reliability Committee with the Risk Manager.

6. Other duties as assigned.

Education: Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related field required. Master’s degree preferred.

Licensure: Certified Professional in Patient Safety (CPPS) or equivalent certification required. New hires/transfers have one (1) year to obtain from date of hire/transfer.

Experience: Three (3) years progressive responsibility in leadership experience. Five (5) years experience in healthcare quality or patient safety, preferably in an acute care hospital setting. Experience leading committees, projects and process improvement. Experience with RLDatix or similar incident reporting systems is strongly preferred.

Pay Range: The hourly rate for this position is $69.15 – $95.00 The range displayed on this job posting reflects the target for new hire salaries for this position.

Job Specifications:

• Union: Non-Affiliated
• Work Shift: Day Shift
• FTE: 1.0
• Scheduled Hours: 40

If you like wild growth and working with happy, enthusiastic over-achievers, you’ll enjoy your career with us!

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