About Sequoia Hospital – Hello Humankindness
Dignity Health Sequoia Hospital is an accredited, not-for-profit community hospital providing innovative and exceptional health care for generations of Bay Area residents. Sequoia’s Heart and Vascular Institute is a nationally known pioneer in advanced cardiac care, affiliated with the Cleveland Clinic Heart and Vascular Institute. Sequoia has received national recognition from Healthgrades for superior patient safety and was named as one of America’s top 100 hospitals for cardiac care. Our Total Joint Replacement program is a designated Blue Distinction Center for Knee and Hip Replacement. Our Birth Center is consistently ranked as a favorite among Peninsula families. We are also known for our comprehensive emergency care and leading-edge tomosynthesis 3-D mammogram technology. Our Pavilion combines the most advanced medical and surgical services with a unique healing environment, including private, spacious rooms and inviting garden areas.
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.
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.
The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.
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