Patient Safety Program Manager RN

At Central Maine Healthcare our team members are committed to providing exceptional care and experiences for our community and for each other every day.

Position Summary:

Responsible for supporting a system wide approach to measure, evaluate and improve patient safety across Central Maine Healthcare. Oversees core measure chart abstraction, reporting and service-line related registry databases for CMH, such as cardiovascular and surgical. Responsible for ensuring the system is compliant with the Maine Sentinel Event law by working proactively to identify, investigate and report sentinel events. Conducts a system wide approach to root cause analysis (RCA), personally conducting, coordinating, facilitating and participating in patient safety related assessments, improvement efforts, root cause analysis and failure modes effects analysis. Will convene, coordinate, lead and align the system leaders in their responsibilities to identify patient safety risks. Chairs the system patient safety committee, whose responsibility is to review individual safety and risk events, determine trends, recommend and implement actions to minimize patient harm, and support the efforts of the organization to achieve zero harm.  Support/facilitate the implementation of systems and processes that promote a culture of safety and reduce patient harm. Coordinates communication with bedside staff and other relevant stakeholders regarding improvements related to adverse events. Manages sentinel event communication and follow-up with appropriate external agencies. This position provides consultation in the development and monitoring of the outcomes of performance improvement initiatives regarding serious adverse events. Identifies areas needed for improvement in order to achieve zero patient harm. Tracks completion of sentinel event action plans including performance of related audits to ensure sustainable change. Ensures the organization meets Joint Commission and Centers for Medicare and Medicaid Services (CMS) standards and regulatory requirements related to Patient Safety. Assists with regulatory preparedness and response activities. Must have strong collaboration skills in order to be successful in this role.

Education and Experience:

• RN, Bachelor’s preferred

• Current clinical license

• 5 years of clinical experience or demonstrated understanding of ambulatory and acute care clinical practices

• Previous experience in performance improvement activities preferred

• Certified Professional in Healthcare Quality (CPHQ) certification encouraged

Essential Duties:

• Oversees core measure chart abstraction and reporting.

• Oversees service-line related registry databases for CMH, such as cardiovascular and surgical.

• Oversees and participates in daily mortality review through review of electronic health record to identify potential unreported sentinel events.

• Oversees and participates in mortality reviews in MIDAS focus study.

• Collaborates with Risk department to identify potential sentinel events that have been reported as an adverse event in MIDAS.

• Oversees investigation of potential sentinel events to determine if sentinel event criteria are met.

• Notifies organizational leadership when it is determined that a sentinel event has likely occurred.

• Oversees and participates in reporting of sentinel events to the Maine Sentinel Event Team (SET) using the proper paperwork.

• Organizes, facilitates and documents root cause analysis (RCA) with key stakeholders to identify the root cause, contributing factors and process changes intended to prevent similar events.

• Submits RCA paperwork to the Maine SET within their established timeline.

• Tracks completion of sentinel event action plans including the performance of related audits.

• Participates on and/or facilitates harm reduction committees and performance improvement teams i.e. Multidisciplinary Fall Committee, Pressure Injury reduction, mortality reduction, code blue review committee.

• Consults other departments as appropriate to collaborate in patient care and performance improvement activities. Facilitates needed changes as directed.

• Engages key stakeholders in leading necessary improvement work. 

• Reviews program results with Director prior to submission.

• Provides information on status of projects to medical and hospital staff on performance and areas of improvement needed.

• Prepares high-level reports for communication to leadership and board committees.

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