Patient Safety Coordinator

Key Responsibilities

Patient Safety & Risk Reduction

• Monitor, investigate, and analyze patient safety events, near misses, and incident reports.
• Conduct root-cause analyses (RCA), failure mode & effects analyses (FMEA), and other safety assessments.
• Support initiatives that reduce hospital-acquired conditions, medication errors, and procedural risks.

Regulatory Compliance

• Ensure adherence to standards set by The Joint Commission, CMS, state health departments, and other regulatory bodies.
• Maintain documentation and reports required for audits, surveys, and accreditation processes.
• Coordinate patient safety–related compliance activities across departments.

Education & Training

• Promote a non-punitive, transparent safety culture focused on continuous improvement.

Data Management & Reporting

• Utilize incident reporting software and quality improvement tools effectively.

Collaboration & Communication

• Partner with nursing, medical staff, quality improvement teams, and administration to implement safety initiatives.
• Participate in safety huddles, committee meetings, and multidisciplinary reviews.

Education:
• Bachelor’s degree in nursing or health care field is required.
• An associate’s degree in nursing or health care field with at least 10 years of directly related work experience may be considered in lieu of a bachelor’s degree.
Licensure/Certification/Registry:
• Current Illinois license in respective profession is highly preferred but not required.
• Certified Professional in Patient Safety (CPPS) and/or Certified Professional in Healthcare Quality (CPHQ) preferred but not required.
• Certified Just Culture preferred but not required.
Experience:
• Minimum of 3 years of healthcare related experience is required
• Demonstrated experience with patient safety and quality improvement principles and practices
• Demonstrated experience with analyzing patient safety risks and events
• Demonstrated experience with working effectively with physicians and operational leaders in an interdisciplinary environment
Other Knowledge/Skills/Abilities:
• Basic understanding of healthcare accreditation/regulatory compliance activities including but not limited to Joint Commission, Center for Medicare and Medicaid Services (CMS) and state regulations
• Basic understanding of safety science principles including just culture
• Demonstrated problem solving skills and ability to consistently exercise sound judgment and initiative in routine situations. Seeks guidance in novel situations.
• Demonstrated effective written and verbal communication in performing assigned duties
• Demonstrated abilities to effectively communicate, collaborate and work through complex and sensitive situations with individuals and groups in a confidential and respectively manner
• Demonstrated skills in developing and maintaining good interpersonal relationships

1. Maintains a current working knowledge of Joint Commission Standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participation, and Illinois Hospital Licensing Act requirements.

2. Assists the Manager of Patient Safety in maintaining a state of constant readiness in coordination with operational leaders at their assigned site(s).

3. Under the advisement of the Manager of Patient Safety, communicates and collaborates with operational leaders on new and pending standard interpretations, updates and clarification. Assists in the development of action plans with the Manager of Patient Safety and operational leaders to support ongoing compliance.

4. Actively participates in accreditation and regulatory survey process.

5. Conducts reviews of patient safety events and leads, apparent cause analyses, root cause analyses and proactive risk assessments as assigned.

6. Investigates external inquiries related to quality-of-care concerns as assigned.

7. Conducts quality indicator reviews and tracer activities related to organizational patient safety priorities as assigned.

8. Maintains the integrity of Memorial Health’s Patient Safety Evaluation System (PSES).

9. Promotes a culture of safety and serves as a resource in just culture principles.

10. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.