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System Director Patient Safety - Corporate

Job Ref: 24002

Talent Area: Administrative Management

Houston Methodist Hospital
Houston, TX 77030

Area/Department: System Patient Safety

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Since its founding in 1919, Houston Methodist has earned worldwide recognition. Houston Methodist is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research. Houston Methodist is consistently ranked in U.S. News & World Report’s “Best Hospital” list and was recently named the number one hospital in Texas. FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 1,119 licensed beds, 73 operating rooms and over 5,000 employees, Houston Methodist offers complete care for patients from around the world.

Job Summary

The Houston Methodist Director of System Patient Safety provides expertise, leadership and support to the organization¿s mission to achieve excellence in patient safety and outcomes.  The Director will serve as a leader of change so that the overall culture of HM is focused on evidence based practice, patient safety, standardization, measurement and excellent clinical outcomes.  The Director fosters a culture of high reliability and deep learning. Goal setting will be done broadly with the entire System and entity senior leadership and leadership in Quality and Patient Safety to maximize high reliability, system design, and learning to sustain the safest hospital system in the world.

1. Provide direction and oversight enterprise-wide patient safety initiatives, enterprise wide implementation of best practices guideline and outcomes.
2. Foster and role model the development of a true culture of safety that values both individual and system accountability
3. Assists Leadership in the development of effective departmental patient safety.
4. Creates an environment of personalized service and engages our patients, staff and physicians.
5. Manages and facilitates all aspects of adverse events and, in collaboration with the System Chief Quality Officer continue development of a proactive patient safety program that includes rounding, real-time feedback on reporting and formal reward and recognition program that includes medical staff.
6. Partners with the analysts within the department to measure, analyze, develop and present reports to various committees, analyzes trends and assists in the development of action plans and follow up for resolution of issues. Tracks, trends, and analyzes events and provides routine reports to leadership, including the TMH Quality Committee of the Board, 

1. Completes expense reports by the 15th of the next month.
2. Obtains appropriate approval for all necessary purchases using approved vendors.
3. Manages budget, to include preparation of proposed annual budgets, as well as, development and submission of mid-year and beginning-of-year capital requests. 

1. Develop goals consistent/compatible with hospital mission, vision and values, as well as Administrative and Medical Staff philosophies and guidelines. 
2. Supporting the core mission of Clinical Excellence by coordinating and leading the patient safety functions, initiatives and processes. 
3. Assist entities in review of all quality initiatives to facilitate the selection of performance indicators.
4. Effectively facilitate Performance Improvement Team Root Cause Analysis Teams and organization wide project team.
5. Participates in and/or oversees investigation of potentially serious incidents and facilitates implementation of improvements.
6. Develop, maintain and refine quality monitoring systems as needed.
7. Participates in quality and patient safety studies as appropriate.
8. Makes recommendations to improve patient care processes and outcomes.
9. Coordinates hospital-wide sentinel event (serious incident) reporting program.
    a. Educates staff about reporting responsibilities.
    b. Manage online reporting system, and provides for communication and education for managers and senior leaders.
    c. Oversees the investigation of sentinel events with the appropriate groups.
    d. Maintains a leadership role in development an institutional culture of patient safety and non-punitive reporting of adverse events.
    e. Coordinates learning and data analysis identified through the incident reporting system.
    f. Oversees the preparation of Root Cause Analyses and assists in assuring the tracking and follow-up of corrective and preventive actions.
    g. Integrates patient safety initiatives into quality improvement teams measurements and goals.
    h. Prepares summary reports for internal leadership review.  Collaborates with the Director of Risk Management and Regulatory Affairs for reporting incidents to the Board of Registration in Medicine and to Department of Public Health.
10. Extensive leadership and direction for all root cause analysis at TMH Must be able to link other relevant measures and activities to the goals for patient safety and ISO 9001.  Measure development will be contingent on patient demand and organizational learning.  
11. Oversight and management of contracts and agreements relating to patient safety publications, reports and technology.
12. Follows all safety rules while on the job.  Reports accidents promptly and corrects   minor hazards.

1. Organizes interdisciplinary order-set development teams according to the MAH development process.
2. Supports clinical path teams leaders in developing systems to collect data, manage variances, and report a summary of variance results.
3. Supports the development of ongoing Patient Safety strategy plans for HM System.
4. Serve as a co-chair of the System patient safety related committees.
5. Create a balance between externally driven HM priorities and initiatives.
6. Provide leadership and guidance to other leaders and staff in goal setting, problem solving, resource management and outcome achievement

1. Participate in the development and dissemination of HM System Patient Safety Program.
2. Provide the development of a work environment that encourages professional growth and development of all staff.
3. Stay abreast of research and best practices in patient safety and quality improvement and shares relevant information with clinical and administrative leaders.
4. Facilitates the implementation of Safety programs across the System.
5. Responsible for ongoing management and continual development of evidence-based medicine.

This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.

Masters degree in Nursing or related ancillary clinical graduate degree.

Ten years of acute care experience with minimum of 5 years management experience in a major academic medical center institution.

State Licensure as appropriate for clinical degree

 Thorough knowledge of  all procedural and administrative  functions and procedures; The  DNV accreditation standards; and regulatory requirements relative to medical staff matters
 Expert knowledge of medical terminology; the functions of other hospital departments; and management principles and practices
 A proficient knowledge of Microsoft products: Word, PowerPoint, Excel Ability to communicate clearly and effectively with all levels of the organization with an exquisite understanding of confidentiality and HIPAA regulations.
 Excellent organizational, analytical, and management skills; flexibility; and the ability to adapt quickly in a fast-paced, changing, and stressful environment

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.