Overview

Baylor St. Luke's Medical Center is an internationally recognized leader in research and clinical excellence that has given rise to breakthroughs in cardiovascular care neuroscience oncology transplantation and more. Our team's efforts have led to the creation of many research programs and initiatives to develop advanced treatments found nowhere else in the world. In our commitment to advancing standards in an ever-evolving healthcare environment our new McNair Campus is designed around the human experience-modeled on evidence-based practices for the safety of patients visitors staff and physicians. The 27.5-acre campus represents the future of healthcare through a transformative alliance focused on leading-edge patient care research and education. Our strong alliance with Texas Heart® Institute and Baylor College of Medicine allows us to bring our patients a powerful network of care unlike any other. Our collaboration is focused on increasing access to care through a growing network of leading specialists and revolutionizing healthcare to save lives and improve the health of the communities we serve.

Responsible for designing, implementing and overseeing the facility Patient Safety Program that promotes a culture of safety and focuses on proactive strategies to eliminate avoidable harm. Leads the organization in investigating, conducting analysis, and in identifying root causes to manage and decrease risks. Ensures appropriate patient safety standards, policies and procedures, standard work processes, and regulatory and accreditation requirements are followed and implemented consistently across the organization. Coordinates requests from the system office claims team related to litigated claims, and collaborates with other key stakeholders to implement learnings from claims.

Coordinates all legal documents related to hospital liability, including the management of subpoenas, Summons and Complaints and other related activities.

Responsibilities

Develops, implements and oversees the organization-wide patient safety program in which the facility adopts a culture of safety and focuses on proactive strategies to reduce harm. Codifies the Patient Safety Program in the facility Patient Safety Plan and manages the reporting, data analysis and evaluation to support the Plan and the Patient Safety Program. Ensures regulatory and accreditation requirements for patient safety are fully met. Provides ongoing education to leaders, clinicians and staff on the science of safety (high reliability, effective communication, sustaining awareness/alertness) and patient safety initiatives. Includes patient safety in new hire orientation presentation (e.g., event reporting expectations, culture of safety).

Oversees the events reporting process, root cause analysis, and event investigation/review. Supports and encourages harm reporting throughout the organization through a non-punitive event reporting system. Participates in system office initiatives and programs to mitigate risks identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices/care. Prepares and presents informative and actionable patient safety reports (to include patient's story of harm) to appropriate committees to include high-level presentations to leadership, Medical Executive Committee and the Board.

Receives and oversees responses to patient complaints/grievances and investigates to solve issues promptly. Acts as an intermediary between patients, staff and family to provide clear communication between all parties regarding any outstanding issues. Seeks input from patients/families involved in harm or close-call events as appropriate.

Coordinates the requests from the system office claims team (related to litigated claims) and collaborates with other key stakeholders to implement learnings from claims. This position also includes the coordination of all legal documents

Qualifications

Required Education and Experience:

• Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.
• Minimum of three (3) years of risk management, patient safety and/or other related professional experience and a minimum of two (2) years of experience managing/ supervising employees and/or vendors.
• 5 years of administrative quality health care experience and relevant clinical experience required.
• 3 years administrative quality leadership required.
• Experience leading quality and/or patient safety initiatives across the care continuum
• Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.

Required Knowledfe, skills, Abilities and Training:

• Experience with the event reporting process, root cause analyses, and event investigation/review
• Experience with patient compliant/grievance investigations and prompt resolution
• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks
• Familiar with all legal documents related to hospital liability, including management of subpoenas, Summaries and Complaints and other related activities
• Knowledge and expertise in specific performance improvement/CQI methodologies (e.g. Six Sigma, LEAN).
• Experience developing and implementing patient safety process improvement initiatives, both small and large scale.
• Current knowledge of accreditation (e.g., TJC) and regulatory requirements of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities
• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these skills

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