CommonSpirit Health
Quality-Patient Safety Program Mgr - Clinically Licensed
CommonSpirit Health, London, Kentucky, United States, 40741
Quality-Patient Safety Program Mgr - Clinically Licensed
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: Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction 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. Overview Welcome to Saint Joseph London, a 150-bed regional hospital founded in 1926. Located on a 52 acre healing environment, Saint Joseph London offers private patient rooms that overlook a small lake and healing garden and has been recognized as a Best Place to Work in Kentucky for five years in a row (2020-2024). Whether you are an experienced healthcare professional or working toward that, we invite you to experience Hello Humankindness with us! CHI Saint Joseph Health provides you with the same level of care you provide for others. Learn more about CHI Saint Joseph London and its awards and recognitions here: CHI Saint Joseph London. Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.
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: Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction 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. Overview Welcome to Saint Joseph London, a 150-bed regional hospital founded in 1926. Located on a 52 acre healing environment, Saint Joseph London offers private patient rooms that overlook a small lake and healing garden and has been recognized as a Best Place to Work in Kentucky for five years in a row (2020-2024). Whether you are an experienced healthcare professional or working toward that, we invite you to experience Hello Humankindness with us! CHI Saint Joseph Health provides you with the same level of care you provide for others. Learn more about CHI Saint Joseph London and its awards and recognitions here: CHI Saint Joseph London. Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.