Mgr Clinical Patient Safety & Regulatory Accreditation

General Description:

The Manager, Clinical Patient Safety & Regulatory Accreditation is responsible for supervising patient safety risk management staff and providing operational leadership for systemwide patient safety and risk management programs across OU Health. Under general direction, this role leads patient safety initiatives, oversees regulatory and accreditation activities related to patient safety, and ensures compliance with applicable federal, state, and local requirements. The Manager partners with organizational and clinical leadership to monitor patient safety performance, identify and mitigate risk, and promote a consistent culture of safety throughout the organization.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Provides direct supervision of patient safety risk management staff and assigned personnel, including workload balancing, work assignment, performance monitoring, and compliance with departmental policies and procedures.

• Conducts annual performance evaluations, provides ongoing coaching and feedback, and supports mentoring and professional development of staff.

• Establishes departmental priorities and coordinates resources to ensure timely completion of patient safety investigations, regulatory activities, and required followup actions.

• Reviews patient safety event reports on an ongoing basis to identify trends, emerging risks, and areas requiring intervention.

• Participates in Root Cause Analysis activities and oversees action plan development, documentation, accountability, and timely completion.

• Develops, reviews, and distributes patient safety metrics, dashboards, and monitoring reports for leadership, committees, and operational stakeholders.

• Collaborates with organizational leadership to establish patient safety goals, monitor progress, and adjust strategies based on performance data and regulatory expectations.

• Oversees the systemwide patient safety risk management and regulatory accreditation program related to patient safety, including implementation of applicable federal, state, and accrediting body requirements.

• Serves as the systemlevel liaison for patient safetyrelated regulatory and accreditation reviews and inspections, coordinating preparation, onsite activities, and postsurvey action plan communication.

• Coordinates accreditation survey activities and ensures staff and providers are informed of survey expectations, roles, and responsibilities.

• Identifies and coordinates external resources, industry tools, and benchmarking opportunities to support advancement of the patient safety program.

• Serves as a resource for providers, leaders, and staff regarding patient safety principles, risk mitigation strategies, and regulatory requirements.

• Represents the department on organizational committees, councils, and workgroups related to patient safety, quality, and regulatory readiness.

• Participates in afterhours and weekend oncall rotation to support response to patient safety events involving patients, visitors, physicians, or employees.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: Bachelor's degree in Healthcare Administration or other related field required.

Experience: At least five (5)years of experience in healthcare, clinical, patient safety, regulatory or risk management, with at least three (3) years of progressive leadership experience required.

License(s)/Certification(s)/Registration(s) Required: Certified Professional in Health Care Risk Management (CPHRM), Certified Professional in Patient Safety (CPPS), or Certified Professional in Healthcare Quality (CPHQ) required within 12 months of hire. Current RN license required.

Knowledge, Skills and Abilities:

• Knowledge of patient safety and risk management principles, including event reporting, investigation, Root Cause Analysis, and performance improvement methodologies.

• Knowledge of federal, state, and accrediting body requirements related to patient safety and risk management.

• Knowledge of healthcare quality and safety systems, including the use of data to identify risk, monitor performance, and drive improvement.

• Strong verbal and written communication skills, with the ability to communicate patient safety findings, trends, and regulatory expectations to leadership and multidisciplinary teams.

• Strong analytical and criticalthinking skills, including the ability to interpret patient safety data, identify meaningful trends, and support datainformed decision making.

• Effective leadership and management skills, including the ability to supervise staff, provide performance feedback, support professional development, and manage departmental priorities.

• Proficiency with Microsoft Office products (Word, Excel, PowerPoint) and reporting or dashboard tools used to support patient safety monitoring and reporting.

• Ability to work collaboratively with clinical, operational, and administrative stakeholders to advance patient safety initiatives and shared accountability.

• Ability to manage multiple priorities, respond effectively to emerging risks, and meet regulatory and operational deadlines in a fastpaced healthcare environment.

• Ability to exercise sound judgment and problemsolving skills in complex or highrisk patient safety situations.

• Ability to maintain confidentiality and professionalism when managing sensitive patient safety and risk management information.