Patient Safety Manager in Lakenheath

Serves as a Patient Safety Specialist in a Medical Treatment Facility (MTF) responsible for implementing patient safety policies and activities developed by the Military Health System (MHS) Patient Safety Program.

• MAJOR DUTIES
• 1. Patient Safety Program Leadership (35%)

In collaboration with the Chief of the Medical Staff, plans, organizes, directs, and manages the Medical Treatment Facility Patient Safety Program to support and advance Air Force Medical Service strategic healthcare safety and reliability objectives.

• Program Management
• Directly responsible for organization-wide patient safety and reliability science activities across inpatient and outpatient settings.
• Enhances process standardization to reduce variability and decrease vulnerability for error.

• Develops patient safety goals and objectives that integrate

• Performance Improvement
• Quality Management
• Serves as the Medical Treatment Facility authority on patient safety matters.
• Advises medical leadership and staff on implementation of the Patient Safety Program.
• Responds to concerns and elevates issues to the Chief of the Medical Staff, as appropriate.
• Recommends patient safety initiatives for leadership approval.
• Performance Improvement
• Collaborates with the Medical Treatment Facility Quality Team and other departments to:
• Identify patient safety events
• Implement and evaluate performance improvement and risk reduction activities
• Reviews patient safety indicators and clinical metrics.
• Analyzes trends and recommends organization-wide improvements.

• Serves as a change agent by

• Researching best practices
• Identifying opportunities for improvement
• Reporting and Communication
• Prepares and presents executive briefings.

• Provides reports to

• Command leadership
• Defense Health Agency (DHA)
• DHA Region-Europe
• Supports Department of Defense and Air Force Medical Service safe patient care initiatives.
• Coordination

• Coordinates with

• DHA Patient Safety Program Consultant
• Patient Safety Data Analyst
• Chief of Patient Safety
• Develops comprehensive risk mitigation and patient safety education initiatives.
• Interfaces with Federal agencies on patient safety matters.
• Coordinates with DHA and DHA Region-Europe offices regarding policies and program responsibilities.
• Regulatory Compliance

Maintains current knowledge of

• Public policy
• The Joint Commission standards
• Do D regulations
• DHA regulations Legislative trends
• Healthcare trends affecting patient safety
• Program Oversight
• Implements Military Health System Patient Safety Program initiatives.
• Serves as Medical Treatment Facility liaison to DHA for reporting and analysis of patient safety events.
• Participates on interdisciplinary committees supporting organizational, regional, and Do D patient safety initiatives.
• Participates in Quality Management Division and Safety Office projects.
• Maintains Patient Safety Program validation requirements.
• Reviews compliance with Military Health System standards and accreditation requirements.
• Performs aggregate trend analyses and recommends improvements.
• Immediately reports nationally significant patient safety concerns to DHA Region-Europe Quality Management.
• Ensures Root Cause Analyses meet technical and implementation requirements.
• Provides education and training to patients, families, and staff.
• Collaborates with Strategic Planning and Clinical Committees to integrate the Patient Safety Program with DHA and MHS initiatives.
• 2. Clinical Patient Safety Program Management (30%)

Responsible for planning, developing, and implementing a clinically based program designed to provide high-quality, safe inpatient and outpatient healthcare under the Military Health System Patient Safety Program.

• Program Administration
• Ensures successful implementation and sustainment of the Patient Safety Program.
• Develops and approves local operating procedures and policies.
• Identifies healthcare process risks and recommends improvements.
• Acknowledges Patient Safety Reports and provides timely staff feedback.
• Evaluates occurrence reports and determines the required level of review.
• Sentinel Events and Root Cause Analysis
• Directs, facilitates, and oversees Sentinel Event investigations.

• Ensures

• Credible Root Cause Analyses
• Development of action plans
• Required reporting through appropriate channels

• Ensures Patient Safety Action Plans are

• Implemented
• Evaluated
• Communicated to appropriate organizations
• Functions as the primary Root Cause Analysis coordinator.
• Ensures lessons learned are distributed throughout the Military Health System.
• Performance Monitoring
• Establishes administrative controls ensuring recommendations are implemented.
• Recommends corrective actions and independently implements resolutions when appropriate.
• Provides routine updates and ad hoc reports.
• Determines event classifications and required assessments.
• Verifies action plans and evaluates organization-wide impact.
• Tracks corrective actions in accordance with Joint Commission standards.
• Uses quantitative and qualitative measures to evaluate intervention effectiveness.

• Collaborates with

• Quality Management
• Chief of Medical Staff
• Coordinates Medical Incident Investigations.

• Facilitates

• Failure Mode Effects Analyses (FMEA)
• Tracks outcomes and reports results to leadership
• Data Analysis
• Reviews Potentially Compensable Event cases.
• Utilizes Patient Safety Reporting systems and analytical tools.
• Identifies causal factors and recommends corrective actions.
• Educates staff on use of Patient Safety Reporting systems.
• Oversees routing and closure of Patient Safety Reports.
• Collects, trends, analyzes, and presents patient safety data.
• Disseminates information to appropriate committees and leadership.
• Accesses committee minutes, medical records, and medical staff files as required.
• 3. Accreditation and Compliance (15%)
• Advising staff on accreditation requirements.

• Researching and interpreting

• Accrediting agency standards
• Do D policy
• Air Force policy

• Preparing the organization for

• Staff Education Visits
• Inspections
• Coordinating implementation of Joint Commission National Patient Safety Goals.
• Monitoring compliance and sustainment of corrective actions.

• Collaborating with

• Quality Management
• Credentialing and Privileging
• DHA partners
• Conducting annual program appraisals.
• Maintaining required records.
• Supporting Congressional inquiries, Inspector General complaints, and Freedom of Information Act requests.
• 4. Education, Culture of Safety, and Strategic Planning (10%)

Establishes mechanisms to educate staff on patient safety principles and foster a culture of safety.

Responsibilities include

• Guiding leadership safety rounds.

• Coordinating

• New employee orientation
• Team training
• Individual consultations

• Educating staff regarding

• Patient Safety Program requirements
• Coaching staff in High Reliability Organization principles.
• Delivering initial and annual refresher training.
• Tracking training requirements using DHA-approved learning management systems.
• Maintaining continuity files.
• Supporting strategic planning efforts.

• Advising leadership on

• Patient safety policies
• Regulatory requirements
• Recommending patient safety initiatives for strategic planning.
• Supporting internal review systems to ensure compliance with accreditation and regulatory requirements.
• 5. Supervision (10%)

Supervises the Patient Safety Assistant Coordinator assigned to the Medical Treatment Facility.

Responsibilities include

• Determining work priorities.
• Assigning and reviewing work.
• Instructing employees on work methods.
• Monitoring employee performance.
• Identifying training needs.
• Developing employee training plans.
• Providing cross-training opportunities.
• Informing employees of organizational policies.
• Managing attendance and leave.
• Resolving informal complaints.
• Interviewing and selecting subordinate employees.
• Developing performance plans.
• Conducting counseling sessions and evaluations.
• Promoting Equal Employment Opportunity and other special emphasis programs.
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