Administers and maintains all department services in accordance with standards and criteria established by TJC, State, Local and Federal agencies to ensure compliance to those external requirements
Develops, directs, plans, organizes and manages all operational aspects of the Safety Management and Environmental Quality division. Develops, reviews, and revises division standard practices, policies, technical, and procedural standards designed to ensure achievement of divisional goals and objectives. Implements and manages approved policies, procedures, standards and operational programs and ensures compliance
Coordinates development of EOC reporting indicators with the management plans and procedures for clinical equipment issues and laser safety. Monitors and tracks effectiveness of established indicators
Ensures response to inquiries and complaints from patients, physicians, staff, and other customers in a manner consistent with Hospital policies and procedures. Develops and directs quality control and performance improvement activities. Participates on appropriate committees, as assigned
Develops, recommends, and maintains safety and loss prevention programs, procedures and regulations which ensure hospital and employee compliance with local, state, and federal safety and environmental regulations
Develops appropriate communication, training, and education programs in support of organizational and regulatory requirements, in safety and accident prevention. Disseminates information to department heads and others regarding toxic and hazardous waste and materials, safe medical devices and supplies, emergency preparedness and other safety information
Conducts risk assessments to identify and prioritize risks in the environment. Provides actionable plans of correction as necessary to reduce or minimize risks
Conducts building and grounds surveillance surveys on a periodic basis to detect code violations, hazards, and inappropriate work processes and procedures. Reviews accident reports, conducts investigations, and makes recommendations to maintain a hazard free environment. Monitors employee exposure to hazardous substances and notifies Employee Health of exposures and recommends employees for medical surveillance
Provides direction and guidance to the department heads of the hospital in support of its mission and specific reference to personnel management, setting organizational goals, performance, etc.
Administers safety direction to the operations and quality of all assigned hospital departments to include job safety analysis, hazard vulnerability analysis and industrial hygiene guidance
Functions as WIRB Biosafety officer or designates qualified Life Safety personnel for said function
Represents the Hospital to others including the public, patients, outside agencies and other sectors of the Hospital
Works collaboratively with department heads to ensure that high quality work is performed, cost effective services are provided to patients and all users within the facility by monitoring standards of practice, customer satisfaction, operational and personnel budgets, and staff performance
Performs personnel management functions, directly or through delegation to department heads, for the designated area to include, but not limited to; interviewing, hiring, scheduling, coaching, counseling, evaluating and terminating employees as delegated by or with the Department Head's approval
Maintains current knowledge of all applicable codes, regulations, standards, and accreditation requirements for area of responsibility
Plans, provides, and evaluates orientation, training, continuing education programs or other opportunities for learning as delegated for the department and other hospital staff
Participates in monitoring and controlling assigned operational and capital budgets within administrative guidelines
Performs other duties and responsibilities that are appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and is not to be considered as all-inclusive