CHI · 2 hours ago
Quality-Patient Safety Program Manager - Clinical Lic
CHI, now part of CommonSpirit Health, is seeking a Quality-Patient Safety Program Manager to oversee the implementation and management of the Performance Improvement plan and Patient Safety Program. This role involves ensuring compliance with accreditation standards, coordinating quality management activities, and supporting regulatory readiness and risk management initiatives.
Health CareHospitalMedicalNon Profit
Responsibilities
Responsible for the implementation and management of the Performance Improvement (PI) plan, the facility Patient Safety Program, including the Patient Safety Plan, and ensuring and maintaining compliance with The Joint Commission and relevant State and Federal regulations related to accreditation and regulatory requirements, quality monitoring and performance improvement
Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) 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
Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures
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. Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues. Supports implementation of regulatory initiatives
Oversees the events reporting process, root cause analysis, and event investigation/review. Supports and encourages harm reporting throughout the organization through a non-punitive just event reporting system. Participates in system office initiatives and programs to mitigate risks identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices/care. Prepares and presents informative and actionable patient safety reports (to include patient's story of harm) to appropriate committees to include high level presentations to leadership, Medical Executive Committee and The Board
Qualification
Required
Bachelors Other, in a healthcare-related field OR five (5) years of related job or industry experience in lieu of degree
Minimum of three (3) years of progressive management responsibility in an acute care setting
one (1) of which is related to managing an organization's Quality Improvement Program including quality improvement methodology and data analysis
Minimum of three (3) years of risk management, patient safety and/or other related professional experience
Experience developing and implementing clinical, service and operational process improvement initiatives
Minimum of two (2) years of clinical, patient care experience or equivalent
Company
CHI
Catholic Health Initiatives, a nonprofit, faith-based health system formed in 1996 through the consolidation of four Catholic health systems, expresses its mission each day by creating and nurturing healthy communities in the hundreds of sites across the nation where we provide care.