Safety Manager   

Department:Quality   

Reports to:Director of QA/QI   

FLSA Status:Exempt   

Type of Position:Full-Time   

Revised Date:3/7/2024   

MISSION & VISION STATEMENT:   

The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is:  “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is:  “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”.    

POSITION PURPOSE:   

Reporting to the Director of Quality Assurance/Quality Improvement, the Safety Manager (SM) oversees two areas within KPHC: safety and security.  This position helps to maintain the broad development, implementation, monitoring and reporting of KPHC’s employee safety programs and initiatives designed to limit chemical, biological, physical, and ergonomic risks to KPHC staff.    

This position helps to advise on regulatory, government and accrediting agency requirements for effective safety programs at KPHC and works across departments to align organizational policies and practices with these standards. Serving on the Infection Prevention Committee (IPCC) and Safety Committee (SC), coordinating closely with the Director of Facilities & Maintenance and the Infection Preventionist. This position also oversees the security team and is responsible for all security aspects of KPHC.   

PERFOMANCE EXPECTATIONS:    

In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following:    

• Uphold all principles of confidentiality and patient care to the fullest extent.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
• Possess and maintain an environment of cultural awareness and sensitivity enabling the facility to fulfill its mission by meeting or exceeding its goals.
• Take responsibility for all day-to-day operations of the facility and health services provided to the patients.
• Maintain a current insurable driver’s license.
• Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well
• Consistently maintains professional and ethical standards adhering to all KPHC Policies, Compliance Standards and HIPAA.

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES:    

• Following Safety policies, monitors the day-to-day implementation of organizational patient and employee safety programs, including surveillance, auditing, and education of staff.
• In collaboration with the Safety Committee, establishment of annual risk assessments and corresponding program and organizational goals for each function based on program intent, operational and environmental analysis, and prior year performance and incidents.
• Oversees KPHC security staff and develops, updates, and renews relevant policies and procedures, with KPHC Leadership collaboration, to provide a safe workplace environment.
• Helps to coordinate and engage annual, quarterly, and monthly surveillance and environment of care rounds/review(s) which includes scheduling, identifying gaps in standards, and submitting proper documentation so the issue is corrected in accordance with accreditation standards of the Accreditation Association for Ambulatory Health Care (AAAHC) as well as other applicable regulatory/required standards.
• Conducts performance evaluations that are timely and constructive.
• Handles discipline and termination of employees in accordance with KPHC policy.
• Assists as a survey liaison with AAAHC and/or other agencies (e.g. CMS) for KPHC’s safety programs.
• Performs risk assessment of work areas to identify hazardous work methods, processes, or materials.
• Provides training and education to KPHC employees and the Health Board on health and safety topics as required, including initial orientation, annual modules, and the KPHC Safety Program for accreditation compliance.
• Helps to perform retrospective and concurrent review of specific focus studies (safe handling processes, environment of care and other studies) requested by staff, department directors, leadership, and committees.
• The safety manager communicates with external agencies as needed for reportable issues (e.g. emergency response coordination) and relays critical issues to the appropriate department(s).
• Maintains current knowledge of pertinent laws, standards, trends, tools, and techniques to maximize safety program effectiveness, including maintenance of applicable professional credentials through continuing education, as required.
• Respond to reports of accidents, injuries, or occupational diseases and investigate the incident(s) to determine causes and preventative measures.
• Maintain all required environmental records and documentation.
• Supply, operate, or maintain personal protective equipment, and provide training to ensure proper use of PPE is being practiced among all employees, contractors, and visitors.
• Ensure personal protective equipment, or other safety equipment such as hearing protection and respirators are accessible to employees.
• Schedule, coordinate, and conduct safety training programs (e.g. Fire Safety, Active Shooter).
• Prepare reports of accidents, injuries, or other incidents for documentation and reporting to designated agencies, safety committee, and leadership as required.
• Maintain inventory of medical, safety, and testing supplies or equipment.
• Test workplaces for environmental hazards, such as exposure to radiation, chemical or biological hazards, or excessive noise.
• Performs other duties as assigned.

MINIMUM MANDATORY QUALIFICATIONS:   

Education:    

• Bachelor’s degree in public health, Occupational Health and Safety, or a related health service delivery profession.

Experience:    

• Two (2) years of healthcare experience in an ambulatory setting, with at least six (6) months direct experience with infection prevention, employee health, and safety program administration.

Certification:    

• Ability to obtain Level 1 or Level 2 Security Certificate within 6 months of being employed.

Mandatory Knowledge, Skills, Abilities and Other Qualifications:   

• Familiarity with AAAHC, OSHA, CMS, and CDC guidelines/requirements regarding environment of care and life safety.
• Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
• Knowledge of mathematics and relevant statistical techniques and ability to perform computations thereof relevant to data reporting and analysis.
• Thorough understanding, knowledge and application of research, analysis, and assessment of compliance with federal regulations related to CMS, HIPAA, Affordable Care Act, and other government laws and programs related to the healthcare industry.
• Knowledge and understanding of the principles, procedures and associated regulations and standards for the delivery of rural, community-oriented health care delivery systems.
• Familiarity with Indian Self-Determination contracting and the IHS system.
• Computer literate and knowledgeable of various computer technologies and software including Word, Excel, HER systems, and other comparable IT platforms.
• Self-motivated, goal oriented and flexibility to adapt to frequently shifting priorities.
• Requires a professional image/demeanor as well as an extremely responsible working attitude with oral and written communication skills being an absolute necessity. Individual must exhibit the highest level of integrity and ethics.
• Ability to maintain a high degree of confidentiality and discretion.
• Frequently required to provide immediate response/assistance to the organization and its employees.
• Knowledge of the Privacy Act, confidentiality and applicable rules and guidelines.
• Extensive knowledge of appropriate accrediting and certification requirements with AAAHC.
• Familiarity with the mandatory reporting requirements under the Indian Child Protection Act, with regards to suspected incidence of child abuse or child neglect.
• Ability to multi-task, work under conditions of stress and meet deadlines.
• Works collaboratively, cooperatively, and in coordination with fellow team members and with others in the organization, treats them with respect, courtesy, and consideration, and shows understanding of the appropriate support of other team members to help get tasks done
• Provides information, guidance, and resources to diverse groups of customers, clients, and others outside of the organization; treats them in a friendly manner with professionalism, helpfulness, respect, courtesy, and consideration at all times
• Complies with all applicable environmental health and safety policies, procedures, and work rules, giving maximum effort to performing job functions in a manner that protects the health and safety of staff, patients, and visitors.

PREFERRED QUALIFICATIONS:    

• Two (2) or more years of direct experience with safety programs, including accreditation and survey preparation activities.
• Two (2) years of proven ability in the areas of leadership, healthcare regulations, infection/injury prevention and safety principles, education outcomes development.
• Certification in Certified Professional in Patient Safety (CPPS), Certified Patient Safety Officer (CPSO) and/or Licenses Healthcare Risk Manager (LHRM) designation(s) preferred.
• Bilingual skills in English and the Keres native language.
• Prior experience working with Indian Health Services (IHS), a Tribe or Tribal Organization.

WORK ENVIRONMENT:    

The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. This position may be exposed to certain health risks that are inherent when working within a health center facility.   

PHYSICAL DEMANDS:    

The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors, and staff.   

MENTAL DEMANDS:    

There are a number of deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.     

OTHER:    

All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.   

Disclaimer:  The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position.  It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.   

Salary Range:   $87,706.00 to $131,559.00