Description: Job Summary:
The Patient Safety Coordinator promotes a culture of safety and ensures appropriate patient safety standards and guidelines are implemented in the delivery of healthcare to our patients, including but not limited to the Medicare Beneficiary Quality Improvement Project (MBQIP), The Joint Commission National Patient Safety Goals, National Quality Forum, and Leapfrog Safe Practices. The purposes of which are to develop, implement, and maintain a comprehensive, proactive processes that promotes: Identification, analysis and prioritization of actual or potential risks. Examination of alternative risk management/patient safety strategies. Selection, communication and implementation of risk management & patient safety strategies for regulatory & accreditation compliance (i.e. Centers for Medicare and Medicaid  Services, Office of Healthcare Assurance, and National Patient Safety Goals, including system changes, where appropriate). Monitoring of those strategies to ensure that the Patient Safety Program is effectively preventing, reducing, and/or controlling injuries or loss and protecting the health of patients. Minimizing potential risks to promote patient safety and enhance the quality of care and services provided to patients. Provides program development and support to Kula Hospital and Lanai Community Hospital staff and leadership in their infection Prevention and Quality Improvement. The Patient Safety Coordinator is accountable to the Hospital Administrator  for implementing and maintaining the same standard of Quality Management and Patient Safety principles that promotes Maui Health System (MHS) culture of safety.

Essential Responsibilities:
Collaborates with various departments/services in the implementation of programs, i.e. National Patient Safety Goals, Leap Frog, and NQF as required by accreditation/regulatory and/or external agencies/bodies.Monitors compliance on patient safety indicators by performing direct observation via patient safety tracers on an ongoing basis and audit activities.Promotes MHS patient safety culture by rounding on inpatient care units and ambulatory areas to perform coaching and mentoring on patient safety issues for staff and physicians.Develops and implements infection prevention and control programs. Identifies infection control problems, disease outbreaks, exposure, epidemics, and pandemics and escalates findings. Analyzes and evaluates data on infection prevention and control programs to identify areas of improvement.  Keeps abreast of current federal and state regulations, as well as professional standards and industry best practicesAssist in review and develops in coordination with appropriate department managers Plan of Correction for deficiencies noted during annual survey inspections/complaint visits and provides a written copy of such plan to the Administrator.  Provides patient safety education to staff, members and physicians.Develops, formulates patient safety reports/learnings to be shared with staff, other committees/teams and leadership as needed and appropriate.Consults with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas and/or improving service  Conducts patient safety risk assessment, designs effective patient safety plan, and annually completes patient safety program evaluation.Facilitates and coordinates implementation/deployment of patient safety system changes, special projects and initiativesCommunicates and disseminates processes/information relative to patient safety best practices and learning at all levels of staff, leadership, and physicians.Represents the medical center on patient safety matters in various programs as assigned.May participate in community / healthcare industry activities to enhance the state of patient safety and clinical risk management.Collects and analyzes data related to patient safety programs and initiatives.Performs risk assessment and other quality improvement tools such as failure modes and effects analysis, root cause analysis, use of analytical tools such as run & pareto charts, PDSA improvement models to facilitate and engage changes in processes for patient safety through identification of process and change ownership identified in action plans.Reports medical errors and near misses, as well as corrective actions taken. Oversee the management and use of medical error information. Review internal error reports and utilize information from external reporting programs to achieve internal outcomes.Participates in the development and implementation of internal audits for TJC, DMHC, CMS, NCQA, DHS, and State Programs compliance.Coordinates the audit process, including reviewing, analyzing, and reporting findings internally to the Director, Senior Leadership, and to Kula Hospital and Lania Hospital Quality Committees.Plans and facilitates Quality meetings for Kula Hospital and Lanai Hospital. Basic Qualifications: Experience
Minimum of two (2) years of nursing experience. Education
Bachelors degree in nursing, health services administration, business or public administration or public health OR four (4) years of experience in a directly related field. License, Certification, Registration Infection Control Certificate within 24 months of hire Registered Nurse License (Hawaii) required at hire
Basic Life Support
Additional Requirements:
Knowledge and skills of patient safety science, culture of safety, human factors, interpersonal and collaborative skills.An ability to inspire and influence others to believe and take action in the culture of patient safety.Effective verbal and written communication skills.Knowledge of risk assessment and quality improvement tools such as failure modes and effects analysis, root cause analysis, use ofanalytical tools such as run & pareto charts, PDSA improvement models. Preferred Qualifications:
Minimum one (1) year experience in clinical risk management, patient safety and performance/quality improvement.Certification as a Certified Professional in Healthcare Risk Management (CPHRM).Training and certification in quality improvement and safe culture programs,CPHQ certificationMaster degree in Business Administration or Healthcare preferred.