GENESIS HEALTHCARE SYSTEM
 

In order to fill our Mission of serving our community by helping each person achieve optimal health and well-being by providing compassionate, exceptional, and affordable healthcare services, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Excellence, Integrity, Team, and Innovation. All employees must regard themselves as an ‘owner’ of Genesis and keep our patients at the center of everything we do - always. 

Position Details:

Work Shift:

Scheduled Weekly Hours:

32

Department:

Quality Management

Overview of Position:

The Patient Safety Consultant is responsible for the management of the hospital’s incident/event reporting system, including staff and managers’ education and for conducting intensive investigation or root cause analysis related to the delivery of safe and efficient patient care. This role is responsible for facilitating management follow-ups and assuring for comprehensiveness of corrective actions. This position works collaboratively with the Risk Management/Legal Department, Nursing Quality, Quality Patient Experience & Service Excellence Department, and other affected department staff to investigate significant and sentinel events and to coordinate the root cause analysis process.

ESSENTIAL DUTIES
1.    Manages the occurrence/event reporting system across the organization and ensures the integrity of data.
2.    Routinely monitors all elements of the occurrence/event reporting systems software, including system dictionaries, user securities, software updates, and interface data transaction and reports.
3.    Analyzes, summarizes, and reports on patient safety activity to hospital and clinic management.
4.    Develops and maintains an ongoing mechanism for monitoring action plans and deficiencies and a proactive process for areas at risk with monthly reporting to the hospital’s committee structure.  
5.    Develops mechanisms for communication of patient safety related information across the hospital and clinics
6.    Disseminates information regarding and promotes use of “best practices” and process improvements in patient safety.
7.    Provides staff and management education on use of the incident reporting system.  Actively promotes the use of the organization’s incident reporting system by physicians, nurses, and other healthcare providers for reporting adverse patient events.  Designs and implements ongoing in-service educational presentations that facilitate the understanding and implementation of patient safety standards within the hospital and clinics.  
8.    Provides staff and management training on the use of the incident reporting system, both one-to-one, Just-In-Time, and scheduled for large groups.  
9.    Recommends specific actions to eliminate or mitigate the risk of patient harm.
10.    Responds to queries for event entry from management, assists with EPIC risk management tools, 
11.    Review all patient incident/event reports and conducts investigations in cooperation with the Risk Management/Legal Department for reported events and patient safety issues, including medical record reviews, interviews, equipment investigations, and reporting to external agencies.  Participates in and leads the review of significant adverse events to gain an understanding of the processes for RCAs.
12.    Establishes processes to ensure that comprehensive review of events is timely, and that information is sufficient for hospital leadership to make a determination regarding regulatory reporting.
13.    Reviews all patient safety and environment of care standards.  Conducts analyses to include trend, pattern, and other statistically valid techniques to assist in focusing program attention and efforts.  Makes recommendations based on findings.  
14.    Serves as a resource for patient care departments and clinics on issues of patient safety and provides patient safety consultation for inquires from physicians, nurses, and other healthcare practitioners.
15.    Serve as chairperson for the Patient Safety Team weekly meetings and administratively assists in preparation for and management of this meeting.
16.    Serve as a member of the HRO meetings and administratively assists with preparation and implementation of this meeting.
17.    Serve as a member of the accreditation regulatory within the Quality Patient Experience and Service Excellence department.
18.    Accurately determines rate of compliance and assists with meeting target benchmarks.
19.    Evaluates compliance with CMS Standards and other regulatory and accrediting bodies, conducts compliance monitoring and actively participates in accreditation surveys.
20.