Director System Patient Safety

Director System Patient Safety

At Houston Methodist, the Director System Patient Safety position is responsible for providing expertise, leadership and support to the organization's mission to achieve excellence in patient safety and outcomes. This position will serve as a leader of change so that the overall culture of HM is focused on evidence-based practice, patient safety, standardization, measurement and excellent clinical outcomes. The Director System Patient Safety position fosters a culture of high reliability and deep learning. Goal setting for this position will be done broadly with the entire system and entity senior leadership and leadership in Quality and Patient Safety to maximize high reliability, system design, and learning to accomplish the expectation to be unparalleled in quality and safety.

The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work-related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations.

Houston Methodist Standard

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED

Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

Provide personalized care and service by consistently demonstrating our I CARE values:

• Integrity: We are honest and ethical in all we say and do.
• Compassion: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
• Accountability: We hold ourselves accountable for all our actions.
• Respect: We treat every individual as a person of worth, dignity, and value.
• Excellence: We strive to be the best at what we do and a model for others to emulate.

Practices the Caring and Serving Model

Delivers personalized service using HM Service Standards

Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

• Directs, develops and implements strategic and operational/high-level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives.
• Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees.
• Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators.
• Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes.
• Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed.
• Provides direction and oversight of enterprise-wide patient safety initiatives and enterprise-wide implementation of best practices guidelines and outcomes. Fosters and role models the development of a true culture of safety that values both individual and system accountability. Assists Leadership in the development of effective departmental patient safety.
• Manages and facilitates all aspects of adverse events and, in collaboration with the Quality Executive Leadership, continues development of a proactive patient safety program that includes rounding, real-time feedback on reporting, and a formal reward and recognition program that includes medical staff. Applies clinical expertise to rounding/reporting processes to ensure effective user experience and quality data analytics for clinical customers.
• Partners with the analysts within the department to measure, analyze, develop and present reports to various committees; analyzes trends; and assists in the development of action plans and follow up for resolution of issues. Tracks, trends, and analyzes events and provides routine reports to leadership, including the HM Quality Committee of the Board.

SERVICE ESSENTIAL FUNCTIONS

• Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction.
• Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department.
• Organizes interdisciplinary order-set development teams according to the MAH development process.
• Supports clinical path teams leaders in developing systems to collect data, manage variances, and report a summary of variance results. Supports a customer service model from System Patient Safety to the entities.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/licensing agency and/or department guidelines as applicable.
• Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety.
• Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.).
• Supports the core mission of Clinical Excellence by coordinating and leading the patient safety functions, initiatives and processes. Makes recommendations to improve patient care processes and outcomes, leveraging clinical expertise to ensure effective understanding and adoption of changes by affected clinicians. Assists entities in review of all quality initiatives to facilitate the selection of performance indicators. Develops, maintains and refines quality monitoring systems as needed.
• Provides extensive leadership and direction for all root cause analysis; links other relevant measures and activities to the goals for patient safety and ISO. Effectively facilitates Performance Improvement Team Root Cause Analysis Teams and organization wide project team. Participates in and/or oversees investigation of potentially serious incidents and facilitates implementation of improvements.
• Coordinates hospital-wide sentinel event (serious incident) reporting program. Educates staff about reporting responsibilities. Manages online reporting system, and provides for communication and education for managers and senior leaders. Oversees the investigation of sentinel events with the appropriate groups. Maintains a leadership role in developing an institutional culture of patient safety and non-punitive reporting of adverse events. Coordinates learning and data analysis identified through the incident reporting system. Oversees the preparation of Root Cause Analyses and assists in assuring the tracking and follow-up of corrective and preventive actions. Integrates patient safety initiatives into quality improvement teams' measurements and goals. Prepares summary reports for internal leadership review. Collaborates with the Director of Risk Management and Regulatory Affairs for reporting incidents to the Board of Registration in Medicine and to Department of Public Health.
• Provides oversight and management of contracts and agreements relating to patient safety publications, reports and technology. Participates in quality and patient safety studies as appropriate.

FINANCE ESSENTIAL FUNCTIONS

• Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current