• Quality and Patient Safety Program Manager

    Catholic Health Initiatives (Garrison, ND)


    Responsibilities

    JOB SUMMARY / PURPOSE

    The primary function of the Quality/Patient Safety Program Manager is to support, coordinate, and facilitate the quality

    management (QM), patient safety (PS) and regulatory performance improvement (PI) activities for the hospital and

    medical 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 confidential

     

    hospital information.

    ESSENTIAL KEY JOB RESPONSIBILITIES

    Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and

    Performance Improvement activities for assigned hospital and medical staff departments, committees, divisions, service

    lines 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, patient

     

    experience, 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 and

     

    reporting of process and outcome measures. Facilitates development and implementation of data collection tools and

     

    processes including the ability to: identify data elements needed to complete appropriate measurement, perform data

     

    collection and abstraction per specifications, and validate data prior to submission or preview reports prior to

     

    publication.

     

    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 these

    regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and

     

    survey preparation activities including mock survey tracers.

    Qualifications

    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/performance

     

    improvement 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 Healthcare

     

    Quality and Management Certification (HCQM), or Certificate of

     

    Professional Healthcare Quality and Patient Safety (CPQPS) within 2

     

    years of employment is required.

    Required Minimum Knowledge, Skills, Abilities and Training

    • Knowledge and expertise of quality management/performance

     

    improvement methods, tools, and techniques (e.g. PDSA, Tests of

     

    Change, Six Sigma, LEAN) and ability to create and support an

     

    environment that meets the quality goals of the organization.

     

    • Current knowledge of data reporting and regulatory/accreditation

     

    requirements for acute and ambulatory care services and federal,

     

    state and local healthcare related laws and regulations and the

     

    ability to comply with these in healthcare practices and activities.

     

    • Knowledge of effective self-management practices and ability to

     

    manage multiple concurrent objectives, projects, groups, or

     

    activities, making effective judgments as to prioritizing and time

     

    allocation.

     

    • Understanding of the necessity and value of accuracy and attention

     

    to detail. Must be able to review patient records and provide case

     

    summaries and maintain the confidentiality of the peer review

     

    process.

     

    • Knowledge of the techniques and the ability to work with a variety

     

    of individuals and groups in a constructive and collaborative

     

    manner.

     

    • Knowledge of the current situation or issue at hand; ability to take

     

    full personal responsibility or ownership for assignments, activities,

     

    decisions and results.

     

    • Knowledge of techniques and tools that promote effective analysis

     

    and the ability to determine the root cause of organizational

     

    problems and create alternative solutions that resolve the problems

     

    in the best interest of the business.

     

    • Ability to work well under pressure and respond to changing needs

    and complex environments

    • Excellent communication skills (oral and written), presentation

     

    style, including the ability to concisely present data to leaders,

     

    clinicians and staff at all levels of the organization

     

    Overview

     

    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.

    Pay Range

    $35.55 - $47.55 /hour

     

    We are an equal opportunity/affirmative action employer.