Quality and Patient Safety Program Manager - CommonSpirit Health Philanthropy : Job Details

JOB SUMMARY / PURPOSEThe 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.

ESSENTIAL KEY JOB RESPONSIBILITIESAssists 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.

Required Education and Experience

Bachelor's degree or higher in a clinical field and three (3) years

clinical experience in an acute care setting. One (1) year healthcare-related quality management/performanceimprovement experience (e.g., chart audit, PI team member, etc.)

Required Licensure and Certifications

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.

Required Minimum Knowledge, Skills, Abilities and Training

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. Understanding of the necessity and value of accuracy and attentionto detail. Must be able to review patient records and provide casesummaries and maintain the confidentiality of the peer reviewprocess. Knowledge of the techniques and the ability to work with a varietyof individuals and groups in a constructive and collaborativemanner. Knowledge of the current situation or issue at hand; ability to takefull personal responsibility or ownership for assignments, activities,decisions and results. Knowledge of techniques and tools that promote effective analysisand the ability to determine the root cause of organizationalproblems and create alternative solutions that resolve the problemsin the best interest of the business. Ability to work well under pressure and respond to changing needsand complex environments Excellent communication skills (oral and written), presentationstyle, including the ability to concisely present data to leaders,clinicians and staff at all levels of the organization

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.