Quality-Patient Safety Program Manager

Welcome to Saint Joseph Hospital, a 433-bed hospital founded in 1877 by the Sisters of Charity of Nazareth as the first hospital in Lexington, Kentucky. Led by Sister Euphrasia Stafford, the mission to provide compassionate care to the underserved is still carried out today. Saint Joseph Hospital holds over two dozen national ranks and recognitions and is recognized as a 2024 Best Place to Work in Kentucky. 

Saint Joseph is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. With approximately 175,000 team members and 25,000 physicians and advanced practice clinicians. 

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 2,200 care centers serving 24 states.

Manager of Quality Patient Safety is responsible for the supervision of a facility-based comprehensive Quality and safety program. The manager, implements and evaluates quality, safety and experience strategies to ensure a well-planned and systematic program for the facility. The Manager implements effective programs, ensuring consistency of best practice implementation and providing oversight and ongoing performance monitoring and action planning on key standardized quality and safety metrics. The Manager leads the efforts to develop and implement standardized plans, processes, structures, strategies and tools for planning and coordinating the daily operations of the Quality department.

The Manager helps ensure continual compliance with regulations and standards set for by Joint Commission and accrediting bodies. In collaboration with Clinical Leadership, the manager supports a comprehensive program to improve patient outcomes and minimize patient harm through the implementation of processes and systems that support a consistent, standardized culture of quality and safety.

The Manager oversees the day to day operations of the Quality and Education teams, influencing and facilitating aspects of evidence based practice and performance improvement with interdisciplinary teams, physicians, clinical leadership and direct care staff. The Manager provides oversight of the department’s quality and patient safety staff and ensures that communication venues and committee forums are in place to ensure mechanisms for reporting and information sharing. The position facilitates the establishment of a data driven culture in the clinical quality and operational areas.

The Manager provides collaborative oversight of the work product that includes Clinical Performance Improvement, Infection Prevention, Accreditation and Regulatory Compliance, Quality Improvement (peer review), Risk Management and Data Analytics / Abstraction /Reporting operations.

The Manager works dynamically, collaboratively and interprofessionally to be responsive to evolving educational needs within his/her oversight. The Manager coordinates clinical education programs, competence initiatives, continuing education and professional development activities to support both nursing and practice areas within the facility. The Manager facilitates the inclusion of both research and evidence-based practice in all educational activities.

Required Education

• Bachelor’s Degree and minimum of 3 years leadership experience OR minimum of 5 years leadership experience in the discipline OR Master’s Degree and no experience. 

Required Minimum Knowledge, Skills and Abilities

• Prior experience within a healthcare setting highly preferred.
• Experience in quality improvement principles, performance improvement methodology, project management and change management preferred.
• Knowledge of regulatory and accrediting standards and Medical Staff Office preferred Patient safety experience and work with High Reliability Organizations / Systems.
• Proven ability to direct and/or facilitate the work efforts of peers and subordinates through teamwork and team building.
• Proven ability to work collaboratively and effectively communicate with physicians, hospital staff, education institution representatives and other professionals Proven ability in project management.

PREFERRED Qualifications

• Registered Nurse OR clinical licensure preferred