OverviewThe primary function of the Quality/Patient Safety Program Manager is to support, coordinate, and facilitate the qualitymanagement (QM), patient safety (PS) and regulatory performance improvement (PI) activities for the hospital andmedical staff. This role also serves as a resource to employees, management, nursing directors, senior management,councils, physicians and teams on quality management activities and will handle patient sensitive and confidentialhospital information.ResponsibilitiesResponsibilitiesAssists in the design, planning, implementation and coordination of Quality Management, Patient Safety andPerformance Improvement activities for assigned hospital and medical staff departments, committees, divisions, servicelines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives,including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patientexperience, efficiency, FMEAS, root cause analyses and medical staff improvement (e.g. case review for peer review,OPPE, FPPE).Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection andreporting of process and outcome measures. Facilitates development and implementation of data collection tools andprocesses including the ability to: identify data elements needed to complete appropriate measurement, perform datacollection and abstraction per specifications, and validate data prior to submission or preview reports prior topublication.Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on theseregulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness andsurvey preparation activities including mock survey tracers.The job summary and responsibilities listed above are designed to indicate the general nature of the work performedwithin this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilitiesrequired of employees assigned to this job. Employees may be required to perform other duties as assigned.QualificationsQualifications
Licensed Registered Nurse, Licensed Clinical Pharmacist, or otherLicensed Clinical Staff and three (3) years clinical experience in anacute care setting
Must be able to perform case reviews for medical staff peer reviewand medical and/or surgical Registry Abstraction
One (1) year healthcare-related quality management/performanceimprovement experience (e.g., chart audit, PI team member, etc.)
Current state license in a clinical field in state of practice.Certified Professional in Healthcare Quality (CPHQ), or HealthcareQuality and Management Certification (HCQM), or Certificate ofProfessional Healthcare Quality and Patient Safety (CPQPS) within 2years of employment is required.
Knowledge and expertise of quality management/performanceimprovement methods, tools, and techniques (e.g. PDSA, Tests ofChange, Six Sigma, LEAN) and ability to create and support anenvironment that meets the quality goals of the organization.
Current knowledge of data reporting and regulatory/accreditationrequirements for acute and ambulatory care services and federal,state and local healthcare related laws and regulations and theability to comply with these in healthcare practices and activities.
Knowledge of effective self-management practices and ability tomanage multiple concurrent objectives, projects, groups, oractivities, making effective judgments as to prioritizing and timeallocation.
Pay Range$30.47 - $44.19 /hourWe are an equal opportunity/affirmative action employer.