Job Summary

The Director of Patient Safety provides leadership and direction in design, development, implementation, and evaluation of a comprehensive Patient Safety Program, ensuring compliance with existing regulations, standards, and internal and external policies and procedures. In collaboration with UCSF Health operational and clinical leadership, and Quality and Safety (Q/S) leadership inclusive of CQO, Vice President, Executive Directors, and Medical Directors of Adult/Pediatric services, the Director participates in setting and implementing the annual strategic priorities for patient safety.

The Director is responsible for providing leadership in the development of a safety culture and in assuring that Joint Commission National Patient Safety Goals are implemented and monitored for effectiveness. Additional responsibilities include: the identification of opportunities and initiatives to enhance patient safety across UCSF Health. In partnership with operational leaders and key stakeholders, the Director develops strategic and operational plans to build a prospective, proactive, loss prevention, and harm reduction patient safety program that results in improved outcomes. Provides oversight to ensure national benchmarks and regulatory requirements related to safety are achieved and maintained.

Supports the Q/S Leadership in developing and enhancing organizational bench strength by building capability and capacity through the organization tiers (frontline to the governing body) by leveraging high reliability principles. The Director of Patient Safety will have a dual reporting to Q/S Executive Directors of Adult Services and Benioff’s Children’s Hospitals.

• Leads strategic planning of patient safety programs across the health system. Oversees the implementation of new initiatives, processes, and performance improvement plans.
• Directs the establishment of systems and standards for all safety reporting, maximizing integration with current systems and providing vision for the future. Develops and implements methods and actions to promote a culture of patient safety.
• Develops and maintains a coordinated approach to safety programs, Ensures the management of adverse events with analysis, intervention, identification of systemic issues, and widespread communications of key learnings. Partners with hospital and physician leadership, operational leaders and safety and quality teams to ensure that organizational wide safety and quality goals and objectives and risk reduction strategies are implemented effectively wherever appropriate while engaging stakeholders in the process. Monitors literature and professional organizations for new and revised best practices related to patient safety, serves as a knowledge leader within the industry.
• Responsible for employee recruitment, performance evaluation and management, and staff development. Instills strong management practices to create a culture of teamwork, collaboration, and timely achievement of objectives and goals.
• Conducts regular presentations to key stakeholders and senior leadership in regards to current patient safety findings and progress, and proposals for new initiatives.
• Ensures management of direct reports to develop relationships with clinical departments and provide training to facilitate the integration of patient safety protocols to benefit the overall clinical enterprise.
• Works with senior leadership and graduate medical education to develop standards for competencies in patient safety.
• Provides strategic leadership and assures the implementation of event reporting processes, organizational responses to events and performance improvement activities.
• Integrates activities with systemwide initiatives, and assures compliance with state reporting requirements.
• Oversees Cause Analysis activities evaluating sentinel and other adverse events.
• Supports the review, investigation and analysis of major adverse events and ensures appropriate trainings and corrective actions are taken to prevent recurrences.
• Oversees the daily management of the Incident Reporting System ( Rl Solutions) including assuring information is communicated in a timely manner through organization tiers to support the safety of the organization. Manages the overall process and improvements for the review, investigation and closure of appropriate Incident Reports.
• Manages, facilitates, and leads periodic safety culture survey administration, analysis, reporting, and improvements.
• Manages, facilitates, and leads annual Leapfrog surveys, and other external ranking initiatives related to patient safety. Manages timely analysis and improvement planning for gaps and opportunities

Department Description

The Department of Quality & Safety consists of Adult Quality & Safety, Benioff Children’s Hospitals (BCH) Quality & Safety, Hospital Epidemiology & Infection Prevention, Analytics & Clinical Effectiveness, Health Equity and Clinical Documentation Integrity. The teams are made of multidisciplinary professionals with diverse backgrounds. The role of the Department is the support UCSF Health to deliver safe, equitable and high-quality care to the communities we serve.

Required Qualifications

• Master’s degree or equivalent in a healthcare related profession including nursing, public health, healthcare administration, or other relevant field
• Minimum of five (5) years of experience in quality or safety leadership capacity and/or clinical management experience, or equivalent
• Strong hospital management experience, with progressive and in-depth expertise in quality, safety and process improvement methodologies, statistical analysis, and database management.
• Excellent skills in developing strategic plans, creating benchmarks, integrating programs, building staff competencies, and organizing operations.
• Excellent leadership and fiscal management skills, with the ability to create a goal-oriented climate of teamwork and collaboration.
• Advanced analytical, organizational, and problem solving skills, with in-depth ability to develop and pursue goals, synthesize data to identify system vulnerabilities and develop and apply innovative solutions.
• Advanced leadership, interpersonal and communications skills to promote, support and introduce quality improvement activities across a broad spectrum of departments.
• Strong knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments.
• Thorough knowledge of patient safety industry best practices in regards to systems, technology and programs.
• Advanced knowledge of patient safety best practices, regulatory requirements and ability to demonstrate compliance.

Preferred Qualifications

• Clinical license (e.g, PharmD, RN, MD, etc.)
• Lean/Six Sigma
• Certified Professional in Patient Safety (CPPS)
• Certified Professional in Healthcare Quality (CPHQ)
• Demonstrated success in implementing organization/health system wide initiatives utilizing improvement methodologies
• Experience in a large multi facility health system/ academic institution

About UCSF

At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what’s possible for the patients we serve – a promise we share with the professionals who make up our team.

Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report – UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents.

Pride Values

UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence – also known as our PRIDE values.

In addition to our PRIDE values, UCSF is committed to equity – both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at diversity.ucsf.edu

Join us to find a rewarding career contributing to improving healthcare worldwide.

Equal Employment Opportunity

The University of California San Francisco is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.