Patient Safety Manager Sr Analyst Functional resume example

Facilitates and implements operational culture of safety and other initiatives for network-wide clinics for Department of Defense (DoD), Defense Health Agency (DHA). Leadership role as engaged Patient Safety Manager (RN license waived) in daily clinical & non-clinical operations of specialty clinics, diagnostics, and ancillary services. Facilitates leadership, directorates departments & clinics in Higher Reliability Organization (HRO) quality for cost-saving regulatory compliant environments.

• Direct day-to-day administrative and operational functions for 4 APU/4-OR Suite bed and Urgent Care facility and 13 specialty clinics.
• Provides guidance and leadership to over 900 employees across more than 10 departments (directorates) within 3 geographic locations: NAS-Lemoore, Monterey CA, and Fallon NV
• Management deliverables adherence to military treatment facility (MTF) mission objectives, the DoD/DHA, Inspector General, and inclusive regulatory agencies.
• Direct, lead, and train employees in best practices in effort to prevent mishaps and promote overall patient safety/environment safety throughout healthcare clinic(s) and associated departmental services.
• Reviews management: staff work processes, time & duration of patient services, labor & staff coverage, patient complaints, review equipment functionality, and initiates team huddles to update staff or address immediate concerns.
• Facilitates organized network-wide schedule to conduct personal walk-about inspections, Executive Leadership rounding inspector, unscheduled mock and scheduled accreditation surveys.
• Reviews and contributes research & discovery for new equipment acquisition with Bio-Med and Specialty Clinic or ancillary service project lead for presentation to Leadership: Finance & IT Directorate.
• Delivers in-service programs or individual requests of up to 150 employees/year for specific guidance.
• Contributes, verifies, and reports QA/CQI and HEDIS metrics/analytics with work group for presentation.
• Reviews network-wide policy & procedure, management plans with impromptu survey readiness checks with new staff and nurse leads (Lieutenants) and other providers.
• Reviews New Hire Onboarding job task requirements, credentialing privileges, and verifies competency completions. Works with Directorate (Head).
• Responsible 'go-to resource' for Patient Safety concerns, Master Trainer & recruits provider trainers for program TeamSTEPPS: Team Strategies & Tools to Enhance Performance & Patient Safety.
• New Hire Orientation presenter (Patient Safety); and back-up for Risk and/or Ethics lead presenters absence.
• Reduced injuries for patients with development and implementation of robust patient & safety programs and policies with Safety Manager (Specialist), Workman Comp Manager, Surgeons, Dentists, and Psychologists through appropriated focus work groups.
• Lead first investigator, Patient Safety Manager (PSM, Specialist) categorizes level of harm event, and assigns review handlers as 2nd, 3rd tier investigators [Lieutenant Commander, LCDR/CDR (Doctor/Surgeon) or Lieutenant (RN)] for input reviews and collaborative plan of actions. PSM & Risk Manager reviews processed 600+ anonymous self-reporting incident submissions/annually.
• Facilitates with Risk Manager Root Cause Analysis (RCAs), Failure Mode & Effects Analysis (FMEA), promoting continuum of improvement 'research & discovery' efforts.
• Collaborates with Bio-Med, Surgical Services, contracts/supply chief for equipment recall, mishap, or new recommendation acquisitions.
• PSM Pre-surveys proposed procedure room or clinic renovation to ensure services & regulatory guidelines adherence prior to detail constructs presentation to finance/facilities at collaborative planning or workforce meetings.
• Oriented and actively promotes staff 'speak-up' for National Patient Safety Goals, HIPAA/Labor, Infection Control program, and Industrial Hygiene advocacy.
• Develops Annual Patient Safety Week and supports all other featured Collaborative Week Recognition Weeks, i.e. Infection Control, Nurses, Physician, All Staff, Lab, ...
• Active audits & feedback to Executive Leadership of critical or process improvement findings in all areas, and not limited to element of performance (EPs) found during patient tracers, universal precaution, medication safety checks, Fentanyl handling observation reviews, staff emergency equipment readiness, & Code Drills Evaluator.
• Engages efforts with staff in hand hygiene, sterilization instrument transport, surgical equipment & supply storage, FIFO inventory levels at clinics, gaseous safety, security enhancement barriers and building evacuations.
• Makes recommendations of housekeeping and maintenance personnel for compliance work performance deliverables and aligned contracts.
• Operating Room Universal Precaution observer & evaluator, and outpatient clinical procedures observations (20-30/month) for QA/CPI efforts.
• Develops and creates post-survey forms customized for specialty clinics findings, plan of action (POA) for The Joint Commission (TJC) Post-Accreditation Intracycle Monitoring (ICM) and Navy Bureau of Medicine & Surgery (BUMED) Inspector General Programs & evidence reviews.
• Engaged a continuum of learning for all staff and recommendation for 'Good Catch' awards, and 'research and discovery' for new 'Innovation' or 'Good Clinical Process' promotion to Agency for Healthcare Research & Quality (AHRQ).
• Works innovative process improvements through Lean Six-Sigma branch team on select deficiency areas.
• Inspected clinic sites and facilities to detect potential health hazards and present advisory corrective measures for immediate consideration with commanding officers.
• Authorized to review supply inventory & storage, equipment reliability, medication & triage processes, staff ratios, patient tracers: reception lobby to procedure to diagnostics staff handling processes to patient exit with EMR documentation audits included.
• Redesigned workflow processes for patient access front through back-office, resulting in focus reduction of staffing costs & shorter time flows by 15-20 % system-wide, including deterring new hire idleness and 5% increase in required corporate compliance modules completions.
• Trained pharmacy interns and newly hired pharmacy technicians of monthly assigned medication inventory & pharmacy site checks monitoring forms completions.
• Reviewed key CAP requirements & presented safety/patient safety updates at lab staff huddles.
• Addressed Wrong Patient, Wrong Site, Wrong Side, Wrong order for radiation patient handling (preventive or actual incident intervention).
• Engaged psychologists and addiction therapists for greater transparency and joint reviews of mutual patients to enhance and optimize recovery time.
• Motivated and supervised 23 Champions and 300+ staff in patient care deliverables, plus medication & equipment.
• Spearheaded and implemented new projects to expand scope of engagement and inter-department cohesiveness.
• Fostered excellence by example by "setting pace" and being hands on mentor to clinical staff with open transparency communication of expectation, goals, and times of completion.
• Generated and reviewed incident reports with leadership including non-punitive write-ups to supervisors, any appropriate corrective action plans to mitigate any recurrence of incident.
• Facilitates organized network-wide schedule to conduct personal walk-about inspections, scheduled department directorate discussions, Executive Leadership rounding, weekly Environment of Care (EOC) rounds, unscheduled mock and scheduled accreditation surveys.
• Increased patient satisfaction scores by 15% average/annually through patient tracers and leadership committing to directorate buy-in and staff awareness.
• Conducted routine facility inspections identifying areas needing improvement: Initiated Maintenance department Evidence Binders receiving good commendation by BUMED inspectors (facilities team just needed guidance and confidence of their efforts through an organized set of evidence binders aka paper trail).
• Collaborative ongoing updates to policies and procedures, maintaining compliance with statutory, regulatory and local, state and federal guidelines relating to HIPAA, benefits administration and general liability, Title XXII.