Director Regulatory And Patient Safety

About Us:

At Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests and treatments, it is about really caring for people with dignity and respect. That’s what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.

Position Purpose:

The Patient Safety and Regulatory Director plays a pivotal role in shaping the strategic direction of Patient Safety and regulatory compliance within the Sinai Health System (SHS). This position involves collaborating with hospital and medical staff leadership to enhance Patient Safety initiatives across all facets of the organization. The Director oversees the formulation of strategies aimed at enhancing the reporting of Patient Safety-related events and ensures that hospital and medical staff leaders and caregivers receive comprehensive training and development in Patient Safety and regulatory compliance. Additionally, the Director continuously evaluates performance improvement, accreditation, safety, and outcomes services to drive ongoing enhancements. They are also tasked with leading regulatory readiness compliance efforts and ensuring the organization is prepared for surveys, while also addressing any findings that arise post-survey.

Key Job Activities:

• Directs survey readiness activities that support continuous compliance with accreditation and governmental regulations, including voluntary, mandatory, and contractual reporting requirements.
• Develops, deploys, and leads the chapter lead model and continuous survey readiness for regulatory readiness for the site.
• Develops, deploys, and executes the survey response process to ensure a dynamic and extraordinary positive experience for surveyors presenting to survey the organization and the site leaders, frontline staff, and providers being surveyed.
• Directs the evaluation, monitoring, and improvement of compliance with internal and external quality indicators and requirements. • Develops, files, and executes plans of correction in follow-up to surveys
• Maintains “expert” knowledge of standards related to accreditation and regulatory bodies, i.e., The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Illinois Department of Public Health (IDPH), Commission on Accreditation of Rehabilitation Facilities (CARF), and Accreditation Commission for Health Care (ACHC).
• Leads and manages the development and ongoing improvement of the Midas Occurrence Reporting System. sinaichicago.org
• Leads, plans, directs, and coordinates the Regulatory Patient Safety programs beyond the operating unit to include system-wide functions or service lines in the Sinai Health Care Regulatory and Patient Safety program, as assigned.
• Designs, leads, implements, teaches, and monitors Regulatory and safety practices, policies, protocols, and methodologies.
• Facilitates an information-based approach to Patient Safety data by utilizing Patient Safety data to evaluate compliance with Patient Safety initiatives and engages department staff/leadership in the use of data to effect positive changes in Patient Safety throughout the system.
• Oversees the development and implementation of a robust Safety Event Classification system utilizing various statistical methods and tools to accurately collect, measure, and assess performance.
• Develops, analyzes, and presents Patient Safety metrics and benchmarks across the System.
• Leads the effective implementation of clinical safety initiatives throughout the Sinai System including the planning, design, development, implementation, and evaluation of clinical quality/safety-related projects and programs.
• Provides an enterprise view of Patient Safety activities; facilitates the building of capacity and expertise for quality improvement; supports internal and community partners in the continuous effort to improve safety.
• Coordinates with the Patient Safety program for the System, Medical Staff leadership, and the caregiver community.
• Acts as hospital liaison to external Patient Safety-related database entities and coordinates SHS participation in external Patient Safety programs such as the Patient Safety Officer (PSO), Patient Safetyrelated grants and other projects
• Oversees administration of the Patient Safety Culture survey and shares results with Staff/Unit/Department Managers, Executive Leaders, and other appropriate groups. Develops ongoing strategies to improve response rate and implementation of identified opportunities.
• Serves in the role of Sinai’s System Patient Safety Leader; collaborates with Patient Safety teams, and operational and medical leadership in analyzing the human, organizational, and system factors contributing to adverse events and works with them to identify and implement risk reduction strategies that promote Patient Safety.
• Co-chairs the Collaborative Patient Safety Committee in partnership with the Chief Medical Officer; Establishes agenda for meetings and conducts/coordinates all follow-up as directed by the committees.
• Develops and disseminates Patient Safety reports to the various Hospital and Medical Staff committees and assists in their preparation for Board meeting presentations.
• Leads and manages the Apparent Cause Analysis (ACA), and Root Cause Analysis (RCA) processes across Sinai.
• Implements and facilitates Patient Safety huddles for all departments in tandem with department leadership to ensure implementation/completion of all RCA activities.
• Drives the development and manages the execution of high-quality, integrated cross-functional plans for projects. Applies project management best practices (relevant statistical tools, and associated methodologies such as RCA, Failure Mode and Effects Analysis (FMEA), and Define, Measure, Analyze, Improve and Control (DMAIC)).
• Conducts periodic reviews of the National Quality Forum (NQF) Safe Practices and Other Similar Benchmarking and Best Practice Processes; Recommends improvements and strategies to the Quality and Patient Safety Committees.
• Collaborates with various members of the hospital’s global quality and Patient Safety team (i.e., Risk Management, Transformational Care, Nursing, Environment of Care, Ancillary Operations, Ambulatory Care, Outpatient, etc.) and assists with the planning and execution of the hospital’s safety strategic plan.
• Develops, implements, manages, and achieves annual Quality and Patient Safety Plans in collaboration with unit leaders.
• Recruits and develops staff, teaches/orients/trains, and manages financial and human resources efficiently and effectively.
• Monitors internal and external trends to identify priorities.
• Oversees effective use of budget and other resources as delegated.
• Maintains high levels of staff engagement and performance.
• Performs other related duties as assigned/required.

Education and Work Experience:

• Bachelor’s degree in health care health-related field required; Health- related field or MBA/MPH/MHA preferred.
• Minimum three years’ experience in quality, safety, regulatory compliance, and/or operations improvement; three years of management experience which includes as a director or manager in directing projects and teams.

Knowledge and Skills:

• Experience Preferred in EPIC and MEDITECH software systems. •
• Demonstrated knowledge of quality improvement principles and practices (i.e., rapid cycle improvement, Six Sigma, Lean, balanced scorecards, etc.), project management, Patient Safety concepts, data analysis, data management, and statistical process control in healthcare.
• Proficient computer skills with extensive experience using various software applications such as MS Excel, Word, Access, PowerPoint; relational database structures, and reporting software.
• Experience with clinical/healthcare software applications preferred; demonstrated knowledge and skills in statistical packages and concepts including control charts.
• High-level skill in the use of complex data in business/value development and the ability to analyze data and draw meaningful conclusions.
• Demonstrated ability to manage projects involving large volumes of data; ability to instruct others effectively; display, analyze, package, and explain data to individuals with varied levels of understanding and abilities; and experience with healthcare collaborative measures across a health system.
• Strong strategic analytical skills for data, product line, and continuum of care analysis.
• Excellent oral, written, “platform” and interpersonal communication skills. Ability to work independently. • High degree of creativity in problem-solving.

Certifications/Licenses:

• Six Sigma, Lean, Certified Professional in Patient Safety (CPPS), and/or Certified Professional in Healthcare Quality (CPHQ) certification desired

Workplace Conditions:

PHYSICAL DEMANDS:

• While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; and talk or hear • The employee frequently is required to walk and stoop, kneel, crouch
• The employee is occasionally required to stand
• The employee must occasionally lift and/or move up to 25 pounds.
• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus WORK ENVIRONMENT: • General office environment and the noise level in the work environment is usually moderate

BLOOD-BORNE PATHOGEN EXPOSURE CATEGORY:

• Category 1 - Job usually involves contact with patients or patient’s specimens. Exposure to blood, body fluids, non-intact skin or tissue specimens, is possible
• Category 2 - Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens
• Category 3 (x) - Job does not involve exposure to blood, body fluids, non-intact skin or tissue specimens. Incumbent does not perform or help in emergency medical care or first aid as a part of his/her job.

Benefits:

Sinai Health System’s goal is to provide you with the most comprehensive benefit package possible while balancing our fiscal commitments and obligations. Sinai Health Systems currently offers its employees the option to participate in a full range of benefits, including a health care program which includes medical, dental, vision and prescription coverage. Along with Employer Paid Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term and Long-Term Disability, Health Savings Account (HSA) and Flexible Spending Account (FSA), Employee Assistance Program and Student Loan Assistance. Participation in some programs requires that employees be regularly scheduled to work a minimum number of hours and/or to have fulfilled a waiting period after they begin employment with Sinai Health Systems. Registry (per diem) Caregivers are caregivers who work less than 1,000 hours in a calendar year. Registry caregivers are employees of Sinai Health System but are typically on an as needed basis. These caregivers may be called upon to cover full-time or part-time caregivers during PTO events or sick leave as well as to provide supplemental coverage. Registry Caregivers are not eligible for Sinai’s benefit programs with the exception for Sick-C, PPO Medical Plan, Employee Assistance Program (EAP) and non-match eligible contribution to the Sinai Health System Consolidated 403(b) retirement savings plan.

Living the Values:

• TEAMWORK - Caregiver works together with other caregivers to create and maintain an inclusive workplace where differences, inclusivity, conflict resolution and open communication are valued •
• RESPECT - Caregiver shows mutual respect and fairness, treats each person with dignity and encourages each individual’s unique talents and contributions
• QUALITY - Caregiver improves our services by following protocol and suggesting improvements based on observations, continuous learning and industry best practices
• INTEGRITY - Caregiver holds self and others accountable for their actions and are honest and ethical in all dealings • SAFETY - Caregiver practices behaviors that promote safety for all patients, visitors, and caregivers
• ROLE MODEL - Caregiver is a dependable role model and champions our values through their daily interactions with patients, customers and coworkers