Specialist - Quality & Patient Safety

Job Summary

The Specialist Quality reflects the mission, vision, and values of EHC, adheres to the organizations Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards (JCIA). Quality Specialist will collaborate with the management team to ensure the quality system essentials exist for all assigned areas. The position holder will be developing and maintaining the quality program for the work unit, representing the department in accreditation inspections. The Patient Safety Specialist is a highly visible position with Advocate Health Care that was created as a result of executive management's desire to mitigate unintentional patient harm, and to reduce liability costs and exposure by reducing clinical risks.

Job Responsibilities 1

Establishes, maintains, supports and documents evidence of an on-going Quality Improvement and Patient safety program which includes effective mechanisms for monitoring and evaluating care rendered

Ensures compliance with applicable laws and regulations

Ensures compliance with approved policies

Evaluates the results of actions taken by individual Hospital/departments/centres and maximizes the efficient use of resources available.

Participates in the planning and development of policies that guide the delivery of Patient care services.

Ensures a hospital wide process to measure , assess data , plan change and sustain improvements in quality and patient safety,

 Provide for staff education on this quality improvement process.

Support Quality Improvement and Patient safety Program and implement a structure and process for overall monitoring and co-ordination

Significant Adverse Events (SAE) Investigation: Performs and manages system-wide investigational reviews to determine if event meets the criteria of an SAE.

Facilitates the formation and ongoing progress of interdisciplinary Root Cause Analysis (RCAs) and Failure Mode Effects

Analysis (FMEAs) events according to The Joint Commission and other regulatory body requirements.

Utilizes an evidence-based approach in case evaluation and proactive educational programs to accomplish patient safety objectives.

Job Responsibilities 2

Prepares and presents patient safety reviews utilizing meaningful written analysis, and data summary reports (charts, graphs, diagrams) to senior leadership and other multidisciplinary meetings.

Provides education across the organization to a multitude of disciplines focusing on patient safety science principles and event or departmental specific needs.

Collaborates with Office of Licensure, Accreditation and Regulation (OLAR) and Risk Management to comply with MoPH regulatory and licensing requirements and organizational bylaws, rules, regulations and policies and procedures.

Participates in the planning and implementation of patient safety events such as the culture of safety survey, patient safety awareness week, the safety fair, etc.

Establishes and maintains uniform, organized filing system and database records. At the direction of management researches, gathers, sorts, compiles and organizes information from the files, from other departments and offices, from outside agencies, etc., for special reports and information requests.

Performs clerical duties as needed to include copying, faxing, filing, retrieval, and assuring that material is processed timely and accurately.

Performs other duties as assigned. Participates in departmental activities that improve processes and efficiency and reduce waste.