Job Description:
Summary:

The Director, Enterprise Patient Safety Systems provides enterprise leadership for administration, optimization, governance, and regulatory alignment of the organization's patient safety reporting system. This position is responsible for system configuration, workflow standardization, dashboard development, event taxonomy, regulatory reporting support, PSO infrastructure, and enterprise patient safety reporting processes. The role partners with Quality, Clinical Operations, Information Technology, and executive leadership to ensure reliable, standardized patient safety reporting and regulatory readiness across the health system. Reports to Assistant Vice President, Risk Management

Essential Job Functions
• Provides strategic leadership for enterprise patient safety systems, infrastructure and regulatory readiness initiatives
• Directs implementation and ongoing optimization of the system wide patient safety event reporting platform
• Oversee enterprise Sentinel Event and Serious Safety Event reporting processes, including governance, workflow standardization, and process improvement
• Directs development and implementation of enterprise patient safety dashboards, performance metrics, and executive reporting
• Leads patient Safety Organization (PSO) participation, reporting strategy, and coordination
• Coordinates organizational readiness for regulatory and accreditation requirements related to patient safety including CMS patient Safety Structural Measure (PSSM), The Joint Commission, Leapfrog, and other regulatory initiatives
• Oversee implementation and sustainment of enterprise patient safety programs, including Great Catch reporting, workplace violence reporting infrastructure, and system safety initiatives
• Collaborate with Information Technology to develop and optimize patient safety reporting systems and workflow automation
• Develop enterprise policies, procedures, standardized workflows, and educational resources supporting patient safety and risk reduction
• Provides consultation and guidance to executive leadership, hospital leadership, medical staff, and operational teams regarding patient safety strategy and regulatory expectations
• Monitors enterprise patient safety trends and recommend system wide improvement initiatives
• Prepares reports and presentations for executive leadership, Quality Committees, Board Committees, and external regulatory agencies
• Serves as subject matter expert for enterprise patient safety initiatives and organizational safety culture
• Collaborate with Risk Management, Quality, Infection prevention, Nursing, Medical Staff, and Operational Leadership to align patient safety strategies
• Support strategic planning and implementation of enterprise safety initiatives
• Performs other duties as assigned

Knowledge, Skills & Abilities
• Expert knowledge of patient safety science and high reliability principles
• Comprehensive knowledge of CMS conditions of participation, The Joint Commission standards, Leapfrog measures, and other healthcare regulatory requirements
• Strong understanding of Root Cause Analysis methodology, human factor engineering, and systems-based process improvement
• Knowledge of Patient Safety Organization (PSO) principles and patient safety reporting requirements
• Experience developing enterprise-wide policies, workflows, and standardized operational processes
• Strong leadership and change management skills
• Excellent project and program management abilities
• Strong analytical and problem-solving skills
• Experience interpreting and presenting complex data to executive leadership
• Excellent written, verbal and presentation communication skills
• Ability to influence and collaborate across multidisciplinary teams without direct authority
• Advance proficiency with Microsoft Office applications, reporting software, and healthcare reporting system
• Ability to manage multiple strategic initiatives simultaneously while maintaining attention to detail
• Demonstrated ability to build relationships with physicians, nursing leadership, executives and operational leaders
• Commitment to fostering a culture of patient safety, continuous learning, and organizational improvement

Requirements:

Bachelor's degree in nursing, Healthcare Administration, Health Information Management, Quality, or related healthcare field required.

Experience: Five years' progressive experience in healthcare Risk Management, quality, patient safety or regulatory compliance

Experience administering enterprise software preferred.

Experience with CMS, Joint Commission, PSO, Leapfrog, and patient safety reporting preferred.

Licenses and Certifications:

Current Registered Nurse license or equivalent clinical credential preferred.

Work Requirements:
Shift: Day
On Call: No
Weekends: No
Travel Required: No Travel
Shift Details: 8a-5p
City/State: Johnson City, TN

Location:
Ballad Health Corporate