Patient Safety Officer - Full Time - #741152

Tahoe Forest Hospital District

Date: 01/15/2022 10:00 AM

City: Truckee, California

Contract type: Full Time

Work schedule: Full Day

Bargaining Unit: Non-represented

Rate of Pay:


Responsible for the enterprise-wide patient safety plan. Responsible to eliminate or reduce the

incidence and severity of harm/loss to patients, families, staff, and the organization. Responsible for

the Beta HEART program. Coordinates the Reliability Management Team. As the Health System Patient

Safety Officer, emphasis is on achieving highly reliable health care through a commitment to the goal

of zero harm; promoting a safety culture, which ensures employees are comfortable reporting errors

without fear of retaliation; incorporating highly effective process improvement tools and

methodologies into our work flows; and ensuring that everyone is accountable for safety and quality.

Essential Duties & Responsibilities:

  • Coordinates the Reliability Management Team (RMT) including meetings and identified initiatives.
  • Develops, monitors and reports activities to improve patient safety, focusing on National Quality

Forum (NQF) Safe Practices, Hospital Acquired Condition (HAC)s, and Institute for Healthcare

Improvement (IHI) and Agency for Healthcare Research and Quality (AHRQ) indicators.

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  • Responsible for patient safety standards in the applicable accreditation survey, state licensure

regulations, and federal conditions of participation.

  • Serves as a patient safety and High Reliability organization subject matter expert. Functions as

process improvement team leader/member to reduce hospital acquired conditions, injuries, errors,

and unintended outcomes. This expertise is provided in various venues as appropriate or assigned.

  • Assists the Risk Manager with the TFHD Event Reporting system, including review of safety,

behavioral, and disruptive events by staff and providers. Provides operational guidance and training to

all staff. Monitors and escalates issues to appropriate Director/Manager and other members of the

leadership team.

  • Identifies and implements patient safety best practice initiatives by reviewing sentinel event alerts,

Patient Safety Organization information, and other key organizations and references. Participates in

event analysis and case reviews.

  • Coordinates the BETA HEART® (healing, empathy, accountability, resolution and trust) program,

which creates a reliable, sustainable, and transparent culture of safety. This includes the annual

culture of safety SCORE survey. Compiles survey results, conducts debriefings, and assists with

identifying plans for improvement with the Director/Manager/Supervisor of each department.

  • Reviews care and treatment provided by staff and providers as part of the peer review or other

event analysis processes.

  • Assists with regulatory compliance, accreditation and state survey process, through staff education

and survey preparedness rounds.

  • Leads process improvement activities, utilizing Lean/Six Sigma principles, with director/managers

and Medical Staff to improve patient safety.

  • Recommends appropriate revisions to new or existing policies related to areas of expertise.
  • Maintains and updates the Patient Safety quality dashboard.
  • Participates in Environment of Care rounds and routinely conducts safety rounding. Provides survey

round recommendations to the director/manager and assists with process improvement and staff

education as needed.

  • Conducts Failure Modes and Effects Analysis (FMEA) as new or revised processes are developed.
  • As assigned, works under the direction of the Director of Quality & Regulations to investigate events,

conduct research, or other relevant activities associated with the department.

  • Prepares and submits summary reports of Patient Safety activities to the Performance Improvement

Committee, Medical Staff Quality Committee, Board Quality Committee, and Board of Directors as


  • Represents the department on appropriate committees as assigned.
  • Ensures compliance with Healthcare Facilities Accreditation Program (HFAP), Centers for Medicare &

Medicaid Services (CMS) and all other federal, state and regulatory agencies.

  • Maintains a clean and safe working environment.
  • Demonstrates System Values in performance and behavior.
  • Complies with System policies and procedures.
  • Other duties as may be assigned.

Minimum Education/Experience:

Bachelor's degree AND 5 or more years of relevant experience

Required Licenses/Certifications:

  • Master's Degree preferred
  • Lean Six Sigma preferred
  • Certified Professional in Patient Safety preferred or acquired within six months of hire

California RN license upon hire

Other Experience/Qualifications:

  • Strong technical knowledge and an understanding of data elements and data analysis
  • Strong analytical and problem solving skills and a strong attention to detail
  • Ability to produce analysis of basic quality measure reporting.

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  • Ability to converse knowledgably with physicians
  • Preferred:
  • Master’s degree
  • Certified Professional in Patient Safety (CPPS) certification
  • Green belt or lean certification
  • Knowledge of EPIC electronic health record

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