Manager, Patient Safety

Focused on the Future of Care We're looking for talented, passionate healthcare professionals to join the team at Memorial Health as we build the future of healthcare. If you're ready to be part of a transformative organization that puts people first, take a look at what we have to offer.

On-site

The Manager of Patient Safety and Accreditation leads Memorial Health’s patient safety program, promotes safe practices, nurtures a just culture and improves processes that detect, mitigate or prevent harm. The Manager enables operational compliance with regulations and standards, facilitates constant readiness activities and guides the organization through the survey process and findings.

• Maintains a current working knowledge of Joint Commission Standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participation, and Illinois Hospital Licensing Act requirements. Serves Memorial Health as a subject matter expert and internal resource.
• Oversees accreditation/regulatory compliance assessments to maintain a state of constant readiness in coordination operational leaders across the health system.
• Facilitates organizational efforts in communicating new and pending standard interpretations, updates and clarifications. Collaborates with operational leaders to develop action plans to support ongoing compliance with accreditation and regulatory requirements.
• Leads accreditation/regulatory survey process..
• Coordinates correspondence with regulatory and accrediting bodies regarding plans of correction and/ or evidence of standards compliance.
• Coordinates response to external inquiries related to quality-of-care concerns.
• Maintains the integrity of the Memorial Health’s Patient Safety Evaluation System (PSES). Informs and educates Memorial Health leaders on the PSES policy.
• Oversee the review of patient safety events and delegates apparent cause analyses, root causes analyses and proactive risk assessments as warranted.
• Coordinates quality indicator reviews and tracer activities related to organizational patient safety priorities, aggregates and disseminates data as warranted.
• Promotes a culture of safety and serves as an expert in just culture
• Coaches and develops team members
• Performs other related work as required or requested.

• Education: Bachelor’s degree in nursing or healthcare field required.
• Licensure/Certification/Registry: Current Illinois license in respective profession is highly preferred but not required. Certified Professional in Patient Safety (CPPS) and/or Certified Professional in Healthcare Quality (CPHQ) required. Certified Just Culture required.
• Experience: More than five (5) years of healthcare related experience is required
• Minimum of two (2) years of previous supervisory/management experience is required
• Demonstrated experience with conducting comprehensive systematic reviews of patient safety events
• Demonstrated experience in applying quality improvement principles
• Demonstrated experience with applying safety science principles including just culture
• Demonstrated experience in healthcare accreditation/regulatory compliance activities including but not limited to Joint Commission, Center for Medicare and Medicaid Services (CMS) and state regulations
• Demonstrated experience working effectively with physicians and operational leaders in an interdisciplinary environment
• Other Knowledge/Skills/Abilities: Possesses an expert knowledge of patient safety and quality improvement principles and practices
• Possesses a working knowledge of accreditation and regulatory standards
• Demonstrated problem solving skills and ability to consistently exercise sound judgment and initiative in all circumstances, including very…