Accreditation Patient Safety Manager RN at AdventHealth

Date Posted: 10/21/2020

Job Snapshot

  • Job Schedule
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
  • Shift
    1 - Day

Job Description


Accreditation Patient Safety Manager AdventHealth Shawnee Mission

Location Address: 9100 W. 74th Street, Mission, KS 66204

Top Reasons To Work At AdventHealth Shawnee Mission

  • Received Magnet® recognition from the American Nurses Credentialing Center in January 2019
  • Providing faith-based, whole person care to Kansas City since 1962 
  • Excellent health benefits, an onsite child care center and fitness facility  
  • Tuition reimbursement to support continuing education
  • Employee Referral Program
  • Largest health care provider in Johnson County with three campuses

Work Hours/Shift

FT Days

You will be responsible for:
  • Implements the objectives of Performance Improvement Plan and Patient Safety Plan
  • Working knowledge of the PSO (Patient Safety Organization)
  • Demonstrates excellent management, communication, organization, interpersonal, problem-solving, critical thinking, systems thinking, consulting, and team building skills.
  • Ability to prioritize, plan and execute while pursuing various projects simultaneously.
  • Readily identifies barriers and develops effective strategies to address.
  • Incorporates patients, physician, and associates needs and concerns into decision-making and organizational action.
  • Provides high-level leadership and collaboration with other departments. 
  • Facilitates meetings and projects effectively, with producible, measurable results.
  • Assures integrity and validity of information used in making associated quality and patient safety decisions.
  • Creates a positive environment that fosters innovation and change. Facilitates the change management process.
  • Seizes opportunities to share “lessons learned” through organizational learning techniques.
  • Demonstrates the ability to delegate responsibilities to all levels of the organization.
  • Supports and encourages error reporting and near miss reporting throughout the organization
  • Leads and facilitates the PI teams, FMEAs, and RCAs as warranted.
  • *Responsible for management of assigned direct reports: recruitment, hiring, coaching/ disciplinary, development, education and competencies, payroll functions and documentation of these activities.
  • Utilizes the Performance Improvement Model
  • Utilizes excellent interpersonal skills to deal with challenging situations while maintaining strong supportive relationships. Readily available for questions; handles requests in a courteous and respectful manner.
  • Communicates effectively, both written and verbally.
  • Demonstrates a proactive attitude and seeks to remedy situations before mistakes are made or corrects errors when found; takes responsibility for the overall “quality image” of the department.
  • Ensures accuracy of data collection and submission; validates integrity of data collected.
  • Develops data reports for projects, committees, hospital departments, medical staff departments, as designated.
  • Knowledge of and utilizes statistical approaches, measurement techniques, including benchmark and comparative data to develop quality reports.
  • Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicates. 
  • Participates in hospital-wide outcomes and quality improvement initiatives/ performance improvement teams.
  • Assists in efforts to improve and streamline the process and workflow of the department.
  • Demonstrates the ability to set appropriate priorities.
  • Recognizes how absence impacts the functioning of the healthcare team and strives to minimize this effect.
  • When requested, is willing to adjust personal schedule in order to complete workload when necessary
  • Attends educational offerings as needed to promote continuous learning and support to department
  • Responsible for staying current on CMS Conditions of Participation (CoP) and Joint Commission standards for all levels of care.
  • Effectively leads patient safety initiatives and adverse event improvements as appropriate
  • Coordinates the  SAQ survey process and Action and Implementation Plans
  • Responsible for Joint Commission Accreditation/CMS CoP Compliance
  • Ensures continuous survey readiness/compliance with accreditation standards
  • Conduct Periodic Performance Reviews for accredited programs
  • Communicates with and educates associates and medical staff on Joint Commission standards
  • Facilitates and coordinates changes necessary to remain compliant-"ever ready activities”
  • Responsible for on-site survey activities (preparation, planning, coordinating, etc.)
  • Serves as the official liaison between SMMC’s accredited programs and the Joint Commission
  • Communicates and facilitates necessary changes in order to remain continuously compliant with accreditation standards.
  • Collaborates with other hospital leaders in developing, monitoring, reporting and analyzing patient safety and accreditation efforts.
  • Proactively seeks opportunities/mechanisms aimed at continually minimizing risks in our patients.
  • Recommends and facilitates change to improve patient safety based on identified risks.
  • Facilitates the creation of an effective action plan in response to identified patient safety issues.
  • Responsible for follow through and oversight for completion and actions plans relating to patient safety, including follow up measures of effectiveness.
  • Participates with leaders from SMMC and medical staff in planning, promoting and facilitating organization-wide patient safety activities.

What You Will Need:
  • Bachelor’s Degree
  • 1 to 2 Years of Position-Related Experience
  • Kansas Registered Nurse License
  • Master’s Degree Preferred
  • 2 to 5 Years of Position-Related Experience Preferred
  • CPPS (Certified Professional in Patient Safety) Preferred
  • CPHQ (Certified Professional in Healthcare Quality) Preferred
Job Summary:
The Accreditation and Patient Safety Manager is part of the Quality Management Leadership team and reports to the Administrative Director of Quality, Risk and Safety.  The Accreditation and Patient Safety Manager has primary responsibility for ensuring Joint Commission standards and CMS Conditions of Participation compliance.  Responsible for Joint Commission continuous readiness for the Hospital, Home Care, Behavioral Health, Shawnee Mission Surgery Center and Prairie Star Surgery Center Accreditations.  Also serves as a resource for hospital identified programs seeking Joint Commission Certification.  The Accreditation and Patient Safety Manager is also responsible for facilitation and coordination of organization-wide Patient Safety initiatives. 

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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