Commonspirit
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Quality Patient Safety Program Manager
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CommonSpirit Health *Overview*
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.
*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 trace. *Qualifications*
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.). 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. Knowledge and expertise of quality management/performance improvement methods, tools, and techniques (e.g. PDSA, Tests of Change, Six Sigma, LEAN). 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. Knowledge of effective self-management practices and ability to manage multiple concurrent objectives, projects, groups, or activities. Understanding of the necessity and value of accuracy and attention to detail. Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner. Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions. *Pay Range*
$30.47 - $44.19 /hour Seniority level
Not Applicable Employment type
Full-time Job function
Quality Assurance Industries
Wellness and Fitness Services, Hospitals and Health Care, and Medical Practices
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Quality Patient Safety Program Manager
role at
CommonSpirit Health *Overview*
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.
*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 trace. *Qualifications*
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.). 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. Knowledge and expertise of quality management/performance improvement methods, tools, and techniques (e.g. PDSA, Tests of Change, Six Sigma, LEAN). 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. Knowledge of effective self-management practices and ability to manage multiple concurrent objectives, projects, groups, or activities. Understanding of the necessity and value of accuracy and attention to detail. Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner. Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions. *Pay Range*
$30.47 - $44.19 /hour Seniority level
Not Applicable Employment type
Full-time Job function
Quality Assurance Industries
Wellness and Fitness Services, Hospitals and Health Care, and Medical Practices
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