Quality-Patient Safety Program Mgr - Clinically Licensed

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

Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians advanced practice clinicians nurses and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2200 care centers serving 24 states.

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.

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.