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ARMY POSITION DESCRIPTION
 

PD#: EX398769

Sequence#: VARIES

Replaces PD#: EX245569

PATIENT SAFETY MANAGER

GS-0601-11

Organization Title:

POSITION LOCATION:

Servicing CPAC: FORT LEAVENWORTH, KS

Agency: VARIES

Installation: VARIES

Army Command: VARIES

Region: SOUTHWEST

Command Code: VARIES

POSITION CLASSIFICATION STANDARDS USED IN CLASSIFYING/GRADING POSITION:

Citation 1: OPM, PCS, GEN. HEALTH SCIENCES, GS-601, JUN 65

Citation 2: JFS PROF WORK IN MEDICAL & HEALTHCARE GROUP, GS-0600, SEP 2017

Supervisory Certification: I certify that this is an accurate statement of the major duties and responsibilities of this position and its organizational relationships, and that the position is necessary to carry out Government functions for which I am responsible. This certification is made with the knowledge that this information is to be used for statutory purposes relating to appointment and payment of public funds, and that false or misleading statements may constitute violations of such statutes or their implementing regulations.

 

Supervisor Name: MARY K POWERS

Reviewed Date: 10/11/2017

Classification Review: This position has been classified/graded as required by Title 5, U.S. Code in conformance with standard published by the U.S. Office of Personnel Management or if no published standards apply directly, consistently with the most applicable published standards.

 

Reviewed By: MAJ ARTHUR R. MATHISEN, DCA

Reviewed Date: 05/24/2012

POSITION INFORMATION:

Cyber Workforce:

  • Primary Work Role: VARIES
  • Additional Work Role 1: VARIES
  • Additional Work Role 2: VARIES

FLSA: EXEMPT

FLSA Worksheet: EXEMPT

FLSA Appeal: NO

Bus Code: VARIES

DCIPS PD: NO

  • Mission Category: VARIES
  • Work Category: VARIES
  • Work Level: VARIES

Acquisition Position: NO

  • CAP:  
  • Career Category:  
  • Career Level:  

Functional Code:  

Interdisciplinary: NO

Supervisor Status: VARIES

PD Status: ARCHIVED

CONDITION OF EMPLOYMENT:

Drug Test Required: VARIES  

Financial Management Certification:

Position Designation: VARIES

Position Sensitivity: VARIES

Security Access: VARIES

Emergency Essential:   

Requires Access to Firearms: VARIES

Personnel Reliability Position: VARIES

Information Assurance: VARIES

Influenza Vaccination: NO

Financial Disclosure: VARIES

Financial Disclosure: NO  

Enterprise Position: VARIES

POSITION ASSIGNMENT:

Competitive Area: VARIES

Competitive Level: VARIES

Career Program: VARIES

Career Ladder PD: NO

Target Grade/FPL: 11

Career Pos 1:    

Career Pos 2:    

Career Pos 3:    

Career Pos 4:   

Career Pos 5:    

Career Pos 6:   

POSITION DUTIES:

MAJOR DUTIES

Serves as the Patient Safety Manager (PSM) with responsibility for implementing patient safety policies and activities developed by the Army Medical Department Patient Safety Program (PSP). Develops and implements the Patient Safety Program systems, and promotes a culture of safety for patients in all healthcare settings. Provides direct support to the development, maintenance, and operation of the Army Medical Department Patient Safety Program at the facility level. Serves as the facility expert on patient safety and trains and consults with personnel within the facility directing patient safety activities of all personnel within the facility including, but not limited to: top level management, leadership staff, department chiefs, physicians, nurses, those involved in direct patient care; and all other Medical Treatment Facility staff. The Patient Safety Manager will train and lead staff as appropriate in the Tap Root concepts (Root Cause Analysis (RCA) or current investigational process being used) in order to promote their role as members of the RCA team, RCA team leaders and RCA recorders. The Patient Safety Manager should be included in all activities involving patient safety issues. Incumbent serves as chairperson of the Medical Treatment Facility Patient Safety Committee and provides the committee and all levels of staff information regarding Medical Treatment Facility, corporate and nationwide Patient Safety updates and initiatives. Serves as the MAHC liaison to the USA MEDCOM Patient Safety Center.

1. Program Planning, Coordination and evaluation. Develops, plans, coordinates, implements, and manages the Patient Safety Program for the organization. Recommends patient safety initiatives to be considered during strategic planning. Prompts staff members to participate in cyclic or special evaluations. Reviews materials with regard to compliance with the standards of the Military Health System Patient Safety Program, external bodies and accrediting agencies. Prepares and reviews aggregate trend analyses, identifies trends and makes recommendations for improvement. Initiates and utilizes the Tap Root method to conduct Root Cause Analysis on all events categorized Safety Assessment Code (SAC) 3 or as directed by the DCCS and/or Commander. Conducts annual Failure Mode and Effects Analysis (FMEA) for high-risk processes needing prospective analysis. Brings to superior's attention, those areas where possible discrepancies exist. Ensures that Tap Roots are complete, that all technical requirements are met, and all implementation requirements are accurately identified and satisfied. Significant concerns identified at the facility which could potentially be issued as a national level alert are immediately brought to the attention of the Chief, QMD, DCCS, Commander and GPRMC Safety Office. Designs and implements educational presentations, which facilitate the attainment and maintenance of patient safety goals. Provides technical expertise in the field of healthcare planning and comprehensive advice and assistance to management regarding possible need for revision of regulations and policies governing planning activities incorporating all appropriate federal guidelines, including MEDCOM Regulation 40-41.
40%

2. Reports Results/Monitors Remedial Actions. Receives and reviews potential patient events from all sections of the MAHC. Centrally manages all patient safety reports. Coordinates appropriate level of review and analysis consistent with disposition of reports. Forwards to Risk Management those incidents requiring standard of care determinations or potential compensable events (PCEs). Maintains the patient safety database. Incumbent will develop, provide and submit reports to Executive Committee, Patient Safety Committee, Risk Management Committee and/or Performance Improvement Committee and MEDCOM as required and/or needed. Establishes administrative controls aimed at ensuring approved recommendations from completed aggregate analysis and Tap Roots are implemented as proposed. Analyzes findings and follows up on actions through referral to appropriate staff members/teams for corrective action. Performs Safety Assessment Code (SAC) analysis of all patient safety events and assigns appropriate SAC category to each event. Establishes a system to track each event and report to MEDCOM per policy.
35%

3. Education. Provides expertise and guidance to staff members in the areas of risk assessment, prospective risk analysis, aggregate analysis, root cause analysis, and development and evaluation of action plans. Coordinates, facilitates and/or educates all Medical Treatment Facility assigned personnel on their roles and responsibilities in the Patient Safety Program, to include reporting of all Patient Safety events, participating in Medical Treatment Facility Patient Safety activities, and educating patients/families regarding all aspects of the safe delivery of care. Oversees the education of the beneficiary population regarding its role in identification of patient safety related issues. Facilitates training for providers on disclosure to patients and families on unexpected outcomes. Ensures effective feedback to all Medical Treatment Facility personnel on lessons learned and process/system improvements that have been or will be initiated.
15%

4. Validates Criteria. Provides support to staff that ensures effective management of the facility's patient safety program. Establishes criteria for internal reviews. Monitors and analyzes changes in mission, goals, new legislation, and technological advances to assess the impact these changes might have on work methods/procedures and identifies ways to address these changes. Recommends patient safety initiatives to be considered during strategic planning. Works with the governing board to formulate new policies and procedures specific to patient safety. Responsible for maintaining current facility policies and procedures related to patient safety. Develops and prepares effective communication strategies regarding patient safety. Compiles, coordinates and prepares facility response to recurring, non-recurring, and special reports requested by Army Patient Safety Program (APSP), Federal, State and National organizations, as well as other organizations with an interest in patient safety programs.
10%

Performs other duties as assigned.

FACTOR EVALUATION DESCRIPTIONS:

FACTOR 1 - KNOWLEDGE REQUIRED BY THE POSITION - LEVEL 1-7 - 1250 POINTS

Knowledge of a variety of professional health care concepts, practices and principles to perform assignments in order to carry out a continuing Patient Safety Program (PSP).

Knowledge of management principles, organizational theory and techniques of analysis and evaluation, along with knowledge of standardized administrative practices and procedures to study, analyze and recommend solutions to problems connected with the evaluation of the medical care efforts within assigned area of responsibility.

Knowledge and skill sufficient to manage a patient safety program with diverse and recognized hazards, achieving compliance with regulatory provisions and effectively communicating multiple safety and occupational health practices and procedures to staff and line personnel.

Knowledge and skill sufficient to plan, organize, direct, budget, coordinate and evaluate a fully developed safety and occupational health program and advise key managerial and executive personnel on courses of action affecting facility operations, work processes, human-machine relationships and environmental conditions which impact on the safety and efficiency of personnel.

Knowledge of a wide variety of medical procedures and diagnoses sufficient to clarify issues with medical staff, note discrepancies, compliance issues and address the situation/problem from a medical perspective.

Knowledge of patient and record documentation requirements/nomenclature, medical procedures and diagnoses sufficient to identify omissions or inconsistencies in records/charts.

Knowledge of health center organization and structure sufficient to facilitate program management and timely resolution of concerns.

Knowledge and skill in applying analytical and evaluative methods and techniques for reviews and studies in order to identify case management issues, determine cost effectiveness and efficient utilization of health center resources and make recommendations for improvement.

Knowledge and ability to evaluate aspects of inpatient and outpatient care to determine best approach and develop alternatives to conventional methods of provision of care and services which will ultimately enhance patient safety goals.

Knowledge of regulations and standards that impact patient safety; of clinical pathways or practice guidelines developed for use in outpatient health care delivery systems; of prevailing techniques for data analysis to identity patterns, trends, and significant issues associated with patient safety programs.

Ability to communicate effectively, both orally and in writing, and to work effectively with professional and para-professional staff members in order to gather data, analyze, present information, coordinate and facilitate activities and findings. Seasoned judgment, tact and diplomacy must be used in order to sway or persuade various audiences to accept findings and adopt recommendations.

Knowledge of automation and its use in data collection and display. Knowledge of and ability to utilize a personal computer in order to enter data, trends, track and retrieve data in a variety of formats (database, spreadsheets, and word processing software).

Knowledge of techniques for data analysis to identify patterns, trends, or issue of significance. The ability to collect, aggregate, analyze and present data and applicable studies.

Knowledge of established industrial systems and methods to improve overall reliability and avoid failures such as Failure Mode and Effects Analysis (FMEA) or Failure Mode, Effects and Criticality Analysis (FMECA).

FACTOR 2 - SUPERVISORY CONTROLS - LEVEL 2-4 - 450 POINTS

Works under the general supervision of the Department of Quality Management/Performance Improvement and guidance of the Deputy Commander for Clinical Services who sets overall objectives and assures adequate resources are available. The incumbent is an expert who plans and performs work independently, coordinates with health care providers and consultants, and resolves most conflicts on own initiative. Coordinates closely with Chief, QMD (PI), Risk Manager, and deputies to establish and implement PI, Patient Safety, Risk Management functions and make recommendations for significant changes that impact the entire facility. Work is reviewed for effectiveness in meeting program goals and objectives and compliance with established policies and procedures.

FACTOR 3 - GUIDELINES - LEVEL 3-3 - 275 POINTS

Guidelines in the form of Federal and State laws and regulations, Department of Defense, Army Medical Department, and service specific directives, JCAHO standards, and other external agency guidance have significant impact upon practitioner and institutional performance. The Patient Safety Manager reviews new Department of Defense and MEDCOM regulations and policies and presents recommendations for refining or developing policies and procedures for the effectiveness and productivity of the Patient Safety Program; provides written guidelines for the staff.

FACTOR 4 - COMPLEXITY - LEVEL 4-4 - 225 POINTS

Employee directs the planning, implementation and evaluation of the patient safety program designed to reduce medical errors and improve patient safety. The Patient Safety Program focus centers on prevention and is a non-punitive approach to improving medical systems and processes. The work involves substantial coordination, integration, and consolidation to develop and manage the program goals and objectives of Medical Treatment Facility (MTF). The work involves implementing policies and strategies related to patient safety. The incumbent has primary responsibility for training and implementing patient safety and Root Cause Analysis processes to clinicians, management, and all relevant support personnel within the MTF. Incumbent establishes and maintains an integrated system of information gathering and reporting mechanisms which define the dimensions of program-related health problems and portray the effectiveness of control efforts. Analyzes such data and assesses program needs in terms of strategies, services, personnel, training, facilities, supplies, and recommends appropriate allocation of resources.

FACTOR 5 - SCOPE AND EFFECT - LEVEL 5-4 - 225 POINTS

The duties of the Patient Safety Manager are to develop, implement, analyze and evaluate various initiatives and activities associated with patient safety. Activities will include oversight for all sentinel event related activities including the root cause analysis of any event or near miss. Activities also include assessment of facility incident reports, product safety reports/recalls, and other patient safety related problems. Programs are designed to provide support to health care management officials with the MTF in the planning, development, and implementation of programs designed to provide high quality, safe patient care.
Incumbent is also responsible for communication between the facility, Western Region Medical Center (WRMC), Medical Command (MEDCOM) and Military Health System Patient Safety Program representatives, both to communicate relevant patient safety information and lessons learned from the facility which have potential impact upon the local level and to understand changes at the national level in the patient safety program.

FACTOR 6/7 - PERSONAL CONTACTS/PURPOSE OF CONTACTS - LEVEL 3C- 180 POINTS

Contacts occurs with employees, supervisors, and managers at all levels within the immediate organization, WRMC, and MEDCOM staff, as well as persons outside of the agency which may include consultants, contractors, or business executives in a moderately unstructured setting.
To influence managers or other officials to accept and implement findings and recommendations on organization improvement or program effectiveness. Incumbent must be able to innovatively resolve conflicts and issues while simultaneously serving as a catalyst for organizational change.

FACTOR 8 - PHYSICAL DEMANDS - LEVEL 8-1 - 5 POINTS

Work is primarily sedentary in nature. On occasion work will require walking and carrying of light items such as books and paper not exceeding 25 pounds.

FACTOR 9 - WORK ENVIRONMENT - LEVEL 9-2 - 20 POINTS

The work is performed in an office setting within a medical facility where there is the possibility of exposure to infection and disease. Protective measures/clothing may be required to minimize exposure. Requires use of computers and computer programs.

TOTAL POINTS - 2630 = GS-11
GS=11 POINT RANGE - 2355-2750





Fair Labor Standards Act (FLSA) Determination = (EXEMPT)

 

1. Availability Pay Exemption - (e.g., Criminal Investigators, U.S. Customs and Border Protection pilots who are also Law Enforcement Officers).

 

2. Foreign Exemption - (Note: Puerto Rico and certain other locations do not qualify for this exemption – See 5 CFR 551.104 for a list of Nonexempt areas.)

 

3. Executive Exemption:

    

a. Exercises appropriate management responsibility (primary duty) over a recognized organizational unit with a continuing function, AND

    

b. Customarily and regularly directs 2 or more employees, AND

    

c. Has the authority to make or recommend hiring, firing, or other status-change decisions, when such recommendations have particular weight.

 

4. Professional Exemption:

    

a. Professional work (primary duty)

    

b. Learned Professional, (See 5 CFR, 551.208 ) (Registered Nurses, Dental Hygienists, Physician’s Assistants, Medical Technologists, Teachers, Attorneys, Physicians, Dentists, Podiatrists, Optometrists, Engineers, Architects, and Accountants at the independent level as just some of the typical examples of exempt professionals). Or

    

c. Creative Professional, (See 5 CFR, 551.209 ) (The primary duty requires invention and originality in a recognized artistic field (music, writing, etc.) and does not typically include newspapers or other media or work subject to control by the organization are just some examples of Creative Professionals). Or

    

d. Computer Employee, (See 5 CFR, 551.210 ) ( must meet salary test and perform such duties as system analysis, program/system design, or program/system testing, documentation, and modification). Computer manufacture or repair is excluded (non-exempt work).

 

5. Administrative Exemption:

    

a. Primary duty consistent with 5 CFR 551 (e.g.; non-manual work directly related to the management or general business operations of the employer or its customers), AND job duties require exercise of discretion & independent judgment.

  FLSA Conclusion:
  Exempt
  Non Exempt


FLSA Comments/Explanations:

Professional series


CONDITIONS OF EMPLOYMENT & NOTES:

This position requires the applicant to perform Temporary Duty 10%.



POSITION EVALUATION:

Career Program 53
COMP Level 00A0
Bus Code AR2844
Comp Area XC

NOTE: The new standard 600 has been applied to this position and resulted in no impact to the classification of the position. 5/7/19 EM

Evaluation Statement:

1. Location: Munson Army Health Center, Fort Leavenworth, Kansas

2. Reference:
a. OPM Nurse Series, GS-0610, Jun 77
b. OPM Administrative Analysis Grade Evaluation Guide, Aug 90
c. OPM Classifier's Handbook, TS-107, Aug 91

3. Title and Series Determination: Management is requesting the position be assigned to the General Health Science Series, GS-601, which covers professional work that is health oriented in character when the work is of such generalized or miscellaneous specialized nature that it is not more appropriately classifiable in any other series within the GS-600 Group or elsewhere. This PSM position requires both a clinical background and professional nursing knowledge, and an understanding of patient safety principles, concepts and methodology in order to improve patient safety in the healthcare setting. Position also requires a high degree of qualitative and analytical skills and the application of mature judgment in problem solving for patient safety issues. Incumbent performs consultant type duties and training to the facilty staff on patient safety. Without a specific series this position classified as 601 for medical speciality. The appropriate title and series is Patient Safety Manager, GS-0601.

4. Grade Determination: The GS-610 standard uses the Factor Evaluation System (FES) that employs nine factors. Under the FES, each factor level description in a standard describes the minimum characteristics needed to receive credit for the described level. Factor evaluation description levels can be found above.
Total points: 2630
Point Range: 2355-2750 = GS-11

5. Final Classification: Patient Safety Manager, GS-0601-11

Classifcation Advisor: Christina Harland 5/24/2012