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Supports Decatur Memorial Hospital’s patient safety program. Facilitates proactive patient safety risk assessments, monitors reported patient safety events, and analyzes patient safety event trends. Participates in the systematic investigation of adverse patient safety events, including root cause analysis. Works in collaboration with the Director of Quality & Safety and Accreditation in assuring ongoing compliance with The Joint Commission (TJC) accreditation standards, Illinois Hospital Licensing Act requirements, and the Center for Medicare and Medicaid (CMS) Conditions of Participation.


  • Master’s degree in nursing or health care field is preferred.
  • 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 master’s degree.


  • Current Illinois license in respective profession is highly preferred but no required.
  • Lean Six Sigma White Belt required within 6 months of hire.
  • Lean Six Sigma Green belt required within 24 months of hire.
  • Certified Professional in Patient Safety (CPPS) is preferred.


  • Minimum of two years of healthcare related experience is required.
  • Minimum of three years healthcare leadership experience is preferred.
  • Three years of demonstrated experience in hospital accreditation/regulatory compliance activities is preferred.
  • Demonstrated experience working effectively with physicians and other healthcare leaders in a multidisciplinary environment is preferred.

Other Knowledge/Skills/Abilities:

  • Demonstrated knowledge in Patient Safety and Quality Improvement principles and practices.
  • Demonstrated critical thinking, decision-making, problem solving, and conflict resolution skills.
  • Self-directed and motivated individual with excellent organizational skills.
  • Proficiency in utilizing common business and clinical software, including but not limited to, data bases, spreadsheets, and statistical analysis and display.
  • Excellent written communication; demonstrated ability to write clearly and concisely, communicating complex concepts accurately.
  • Sound verbal communication and presentation skills; ability to speak clearly and persuasively in positive or negative situations. Ability to effectively communicate, collaborate and work through complex and sensitive situations with individuals and groups.
  • Ability to analyze complex clinical and organizational events.
  • Expertise in facilitation and management of group processes focused on systems thinking and objectively assessing and modifying workflow processes to improve safety and quality.
  • Proficiency in reading, analyzing, and interpreting regulatory documents; experience in investigating and preparing response inquiries.


  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. Provides updates and clarifications on issues of concern to individuals and groups within the health system. Supports organizational efforts in communicating new and pending standard interpretations, updates and clarifications.

  1. Assists the Director of Quality & Safety in facilitating frequent system-wide assessments to quantitatively and qualitatively assess regulatory compliance to maintain a constant state of readiness. These activities are completed in coordination with the ongoing work of the DMH Teams on survey readiness, Memorial Health System quality & safety and operational leaders.

  1. Works in collaboration with department leaders in developing action plans related to assuring ongoing compliance with accreditation and regulatory requirements.

  1. Serves as a leader of the DMH safety committee. Serves as a subject matter expert related to ongoing revisions and additions to Joint Commission standards as they relate to ongoing compliance.

  1. Assists in the dissemination of Joint Commission Sentinel Event Alerts and National Patient Safety Goals. Facilitates proactive risk assessments related to TJC Sentinel Event Alerts. Assists in the ongoing monitoring of compliance with Joint Commission standards and CMS Conditions of Participation.

  1. Produces presentation materials related to patient safety science concepts and accreditation/ regulatory activities for internal committees, work groups, medical staff and leader education.

  1. Participates in activities related to the culture of safety survey including but not limited to pre-survey preparation, survey execution and post-survey action planning.

  1. Facilitates prevention, identification and reporting of safety issues and problems, role-modeling non-punitive approaches to issues.

  1. Assists the System Director of Patient Safety and Accreditation in the execution of the Support for Second Victims program and serves as a Trained Supporter.

  1. Participates in audits and tracer activities related to organizational patient safety priorities, aggregates and disseminates data related to these audits.

  1. Gathers data detailing patient-related errors, and conducts analysis detailing the cause of the error; recommends changes to procedures, policies, and/or programs that could prevent future errors.

  1. Facilitates analyses of actual and potential patient safety occurrences to improve systems and processes (e.g., Patient Safety Debriefings, Cause Mapping, Failure Modes and Effects Analysis).

  1. Facilitates the investigation and preparation for presentation of the systematic comprehensive review and analysis of serious patient safety events to the Root Cause Analysis Leadership Team. Facilitates the efforts of RCA Action Teams when they are formed.

  1. Serves as a patient safety representative on value stream management teams as indicated.
  1. 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.

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