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Healthcare Safety Specialist (Nurse)

Entourage Consulting LLC
San Diego, California, United States
March 25, 2019


Entourage is seeking to hire a Healthcare Safety Specialist (Nurse)

Places of Performance:

Annapolis, MD

Naples, Italy

Pensacola, FL

New England, Newport, Rhode Island

Corpus Christi, TX

Jacksonville, North Carolina

North Chicago, Illinois

California (San Diego, Twenty-Nine Palms, Lemoore)

Virginia (Portsmouth, Quantico)

General Description:

Patient Safety Specialist / Healthcare Safety Specialist (Nurse) shall serve as part of the Risk Management/Quality Assurance team and shall work closely with Military Treatment Facility (MTF) staff for optimization of the Patient Safety Program (PSP). Patient Safety is separate and distinct from environmental safety. The Patient Safety Specialist shall be responsible for the collection, analysis, tracking of progress, display of data, completion and submission of reports, training and education, presentations and meetings as it relates to the MTF's PSP.

Specific Tasks:

• You shall review and monitor the Patient Safety Program (PSP) policies/practices including implementation of all applicable National Patient Safety Goals, DoD Patient Safety Culture Survey results, Navy PS Culture and Change Plan measures, Sentinel Event and FMEA corrective actions and The Joint Commission (TJC) survey findings of all areas for adherence to, and compliance with BUMED, regulatory agency and accreditation standards requirements. You shall route new events in the PSR system to the appropriate POC in the database for action.

• You shall prepare the MTF for internal and external reviews by conducting tracers and making rounds on the different units and clinics. You shall look for compliance with National Patient Safety Goals (NPSGs) documenting observations made during rounds/tracers and sharing observations with QA and RM staff to make sure the MTF is compliant with all PS policies.

• You shall conduct daily, weekly or monthly evaluations of the implementation of facility wide PSP activities, policies, and procedures to ensure overall effectiveness using approved methodologies to include tracers and direct observations.

• You shall work with QA and RM to ensure alignment of patient safety and quality improvement activities and risk reduction strategies.

• You shall assist in the collection, review, processing, categorization, and tracking of patient safety event reports. This includes all patient safety events regardless of the degree of harm.

• You shall provide assistance to MTF Leadership, QM, Patient Safety Manager, and RM, in identifying patient safety trends. Assistance includes collating, analyzing, displaying, and putting data results in a typed paper or spreadsheet.

• You shall prepare briefings on PSP activities to include PS trend reports on types of events seen, if there is an increase or decrease in harm and/or no harm events reported, tracer results and findings from the patient safety rounds to the QA or MTF Leadership for presentation to committees, department heads, directorates, and leadership meetings including quarterly summaries of program activities. These briefings are prepared monthly or as needed.

• You shall provide reports, recommendations, and insight on the overall functioning of the PSP to MTF Leadership, QA and RM semi-annually.

• You shall verify the Tracers on fentanyl patch use, medical gases and medication reconciliation were completed semiannually.

• You shall report tracer results to the MTF quality/safety committee and to the appropriate department heads within one week of completion of the rounds or at the next committee meeting, whichever occurs first.

• You shall discuss with the QA and RM department the priorities for PS Week activities and develop a written plan for the execution of the activities.

• You shall develop and prepare flyers, educational material, and coordinate activities for use at the MTF during the annual National PS Week.

• You shall identify materials available through the DoD PSP website which the MTFs can order free of charge to help support the program and PS week. Educational materials include book marks, badges, and designed spaces for identifying errors.

• The planned activities and materials to be used shall be briefed to MTF Leadership. The lessons learned from the National PS Week activities shall be summarized and made available for MTF Leadership, QA and RM for review and input.

• You shall perform random audits of corrective actions implemented following an RCA or FMEA to ensure continued compliance and sustainment within the MTF at least monthly for four months.

• You shall perform 15 direct observations each month on the use of the Universal Protocol and provide the results to the MTF Commanding Officer (CO) by the 10th day of each month.

• You shall perform direct observations, assessing how staff members implement the current TJC NPSG and/or implement other PS practices as per MTF policies and provide informal teaching on the NPSG and any command policies that relate to them at least monthly.

• You shall perform FMEAs every 18 months per TJC accreditation requirements. You shall guide the MTF in the selection of a topic and facilitate the team appointed by the CO.

• You shall encourage all staff to complete the DoD Culture survey and address any concerns or questions with regard to the survey questions.

• You shall serve as the Point of Contact for the culture of safety survey questions.

• You shall access the PSR system at the MTF, so they can be familiar with the events occurring and note who is assigned to each event for review. You shall communicate with the staff and make sure the correct interventions have been taken to avoid repeat occurrences.

• You shall ensure patient safety event reports are entered and processed in the DoD PSR tool regardless of the medium in which the report was initially submitted (electronic, phone or paper).

• You shall notify the risk manager and the quality manager of any event that meets TJC requirements of a sentinel event, serious reportable event, an unanticipated death or an event with permanent harm as soon as they identify the event falls into one of these categories.

• You shall monitor compliance with National Patient Safety Goals (NPSGs) that are “owned” by other groups within the MTF quarterly.

• You shall facilitate Root Cause Analysis (RCAs) with a group of medical professionals from the MTF on cases involving unanticipated death or serious permanent harm whether or not meeting TJC /SRE reporting requirements.

• You shall submit the RCA to the MTF QA department for CO approval prior to forwarding to the Region, BUMED and TJC.

• You shall send a draft RCA to BUMED RM 5 days before it is due to the leadership of the MTF if no causal factors or corrective actions are addressed in the review.

• You shall label each page of RCA/CSA and Patient Safety Event reports with the 10 USC 1102 QA information tag.

• You shall complete SE/SRE RCAs within 45 days or the individual timeline set by TJC unless TJC grants an extension to the MTF.

• You shall submit the measures of success to the TJC four months after TJC accepts the RCA.

• You shall perform FMEAs every 18 months according to the accreditation requirements set by TJC.

• You shall submit the number of staffs receiving TeamSTEPPS training, in high risk and general areas, to the MTF CO by the 5th of the month.

• You shall audit the clinics for regulatory compliance in addition to the main MTF. Branch Clinic audits are considered site visits.

• You shall provide education and training on patient safety topics within the MTF and the BHCs.

• You shall provide training on entering data into the (Patient Safety Reporting) PSR system, addressing what, how and why the information is placed in the PSR, and the process for following up on the findings/recommendations from Root Cause Analyses (RCAs) and Failure Modes and Effects Analyses (FMEAs) to ensure the corrective actions derived from the RCAs and FMEAs have been implemented and are getting the identified results.

• You shall participate at a minimum every 6 months or as needed in face to face department patient safety refresher training for inpatient and outpatient clinical departments.

• You shall develop patient safety related educational materials that address the unique needs of the MTF professional medical, nursing staff and support patient care staff.

• You shall provide just in time training for the RCA team members explaining their role and how to complete a RCA report using the taproot process.

• You shall observe the use of the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) tools by staff in high risk areas to include briefing, debriefing and huddles.

• You shall promote event reporting in the PSR among all staff at the MTF during leadership, TJC and Environmental rounds and tracers.

• You shall arrange for monthly training for investigators on the PSR system or when new staff arrive if the cycle is not monthly.

• You shall use the taproot process for conducting RCAs and to complete the RCA report.

• You shall participate in weekly leadership rounds, weekly tracers, annual PS Week activities, team training programs, BUMED Risk Management (RM) Teleconferences and BUMED PS training activities as they are announced. The BUMED teleconferences are held every two months for approximately two hours.

• You shall prepare a monthly report for each MTF/clinic summarizing the activities of the PSP for the designated committees.

• You shall present the progress made on the key culture safety initiative tasks each month.

• You shall attend the MTF scheduled quality oversight meetings related to infection control, environment of care, quality/PS committee and other committees as invited.

• You shall meet weekly with the RM/QA leads to review any adverse events, near misses and review strategies and goals for the PSP.


• You must possess a Baccalaureate Degree in Nursing or another healthcare related field.

• You must possess a minimum of three years of experience working in a risk management, patient safety, or quality improvement department in a clinical setting within the last three years.

• You must be a U.S. Citizen.