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Quality Patient Safety Program Manager

CommonSpirit Health

Posted on: 11 Mar 2024

Job Location: Redding, US

Job Description:

Overview

For more than 70 years Mercy Medical Center Redding has offered comprehensive health care in the North State providing acute care and a full range of medical services. The 267-bed hospital offers major medical services including a Level II Trauma Center as well as specialized Cardiovascular Care Stroke Care Orthopedics Neurological Surgery Comprehensive Cancer Care Maternity Care and da Vinci Robotic Surgery. It is the sole provider of obstetrical services along with the only Level III Neonatal Intensive Care Unit in Shasta County. In addition the hospital's network of care includes Mercy Home Health and Hospice and Dignity Health Connected Living. Mercy Medical Center Redding is a member of the Dignity Health system and is a sister facility to St. Elizabeth Community Hospital in Red Bluff and Mercy Medical Center Mt. Shasta. As one of the area's largest non-profit employers we are proud to give back to the community by providing many programs and services to benefit overall health.Visit to learn more.

Responsibilities

Position Summary:

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.

Principal Duties and Accountabilities:

- - Assists in the design, planning, implementation and coordination of QM, PS and PI 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, and root cause analyses and medical staff improvement (e.g. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review.
  - 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

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.)
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.

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