The Joint Commission

Patient Safety Specialist

Job Locations US-IL-Oakbrook Terrace
Job ID
# of Openings



The Patient Safety Specialist responds to patient safety issues brought to the Office of Quality Monitoring (OQM) through a number of routes or sources. Activity surrounding the identified issue is commensurate with the nature and severity of the issue, with increasing responsiveness based on the urgency and seriousness of the patient safety concern. Critical thinking and clinical expertise is applied throughout the process of working with an accredited organization in responding to patient safety concerns. A collaborative approach, mindful of the patient experience, the healthcare provider or organization experience, and of other stakeholders (e.g. government agencies), is essential.  Most interactions on these issues are held with executive leadership of the healthcare organization, such as the Chief Executive, Chief Nursing Officer, Chief Medical Officer, or immediate designees.



  1. Responds to information about healthcare organizations which comes into OQM by evaluating submitted information against Joint Commission requirements, and the impact or potential impact on a patient(s). Consults with other division experts as needed. 
  1. Triages this information in accord with complaint protocols, Medicare Requirements, and with sentinel event policy and takes action accordingly. Assimilates other known information about that healthcare organization for issues of the greatest urgency and makes recommendations to senior leadership regarding the need for on-site survey activity. 
  1. Facilitates for-cause survey activity. Ensures that resulting on-site survey activity is scheduled through the scheduling unit to occur within the defined timeframe, collaborates with field directors as necessary to identify the appropriate field representatives to conduct the survey and provides materials and any information needed in order for the field rep to conduct the survey. Determines time and survey complement to best meet the needs of the clinical concern. 
  1. Initiates interaction with the healthcare organization when the information suggests the incident meets criteria as a reviewable sentinel event, to confirm reviewability and to determine the method by which the organization will complete and submit their root cause analysis. 
  1. Upon submission of the RCA, provides feedback and guidance to the accredited organization�s leadership (either through conference call, web discussion or face to face dialogue), to establish that a thorough and credible RCA has been completed, and ensures that improvement plans are related to the causal factors, and that measurements and implementation are in place. 
  1. For adverse events not meeting the reviewability criteria, works with the organization through the �organization response� process, to evaluate their response to the complaint, to assess the organization�s current status in terms of standards compliance, and to identify whether or not the response is substantive and factual and thus, acceptable to bring cases to closure.  
  1. For issues which are at a priority level that do not require the activities described above, applies a Priority Focus Area to the information and enters it into the database in order to track the issue over time and monitor for trends. 
  1. For issues which have reached a point of completion, provides follow-up with the complainant in a sensitive manner, sharing information as allowed by the Public Information Policy in order to provide closure.  
  1. Responds to data requests in a timely manner providing correct background to frame the data accurately, and to be in accord with the Public Information Policy for both internal and external requests. Responds to the Complaint and to the Sentinel Event Hotline as needed, for issues of immediate concern. 
  1. Interacts with other internal customers and advisory groups, such as research, standards development, and the Patient Safety Advisory Group, to provide information about patterns and trends noted in aggregated OQM data. 
  1. Collaborates with Legal Affairs and Compliance on issues related to confidentiality, retaliation concerns and other legal issues in the clinical setting. 
  1. Effectively communicates with internal and external customers in a respectful, constructive and collegial style consistently providing excellent customer service. 
  1. Provides education to healthcare organizations or others about The Joint Commission�s process for responding to sentinel events, complaints, and for-cause surveys. 
  1. Serves as a role model in the support of and implementation of enterprise, division and departmental mission and initiatives utilizing RPI tools and strategies as indicated. Leads and/or participates in internal work groups to identify and implement improvements to our internal processes.



  1. Healthcare clinician with a master's degree. 
  1. A minimum of five to seven years recent clinical experience providing direct patient care. Management experience preferred. 
  1. Experience in quality improvement, risk management, or patient safety preferred.  
  1. Experience in data management, statistics, or LEAN/Six Sigma preferred, in order to assimilate information and to recognize trends and vulnerabilities in processes. 
  1. Demonstrated ability to empathize with the experience of patients and their families.  
  1. Demonstrated ability to interact with the executive leadership of an accredited organization about serious patient safety risks. 
  1. Demonstrated excellent customer relationship management skills. 
  1. Interpersonal skills to interact effectively with individuals at various levels both inside and outside of the organization, often in sensitive situations. 
  1. Demonstrated analytic, coaching and diplomatic skills. 
  1. Strong writing and speaking skills. 
  1. Knowledge of Joint Commission sentinel event alerts, survey process, standards, national patient safety goals and requirements preferred. 
  1. Demonstrated ability to function well in a fast-paced and challenging environment. 
  1. Strong computer skills preferred including word processing, databases and spreadsheets

This job description is intended to describe the general nature and level of work performed by an employee assigned to this position.  The description is not an exhaustive list of all duties, responsibilities, knowledge, skills and abilities, and working conditions associated with this position.  All requirements are subject to possible modification due to business needs and/or reasonable accommodations for individuals with disabilities.



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