Come join our fast-growing team! As our new Quality and Patient Safety Program Manager (licensed), you will 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. Will handle patient sensitive and confidential hospital information.
- 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.
- Directs programs involving risk mitigation/management and initiatives related to providing safer care to patients. This position is responsible for providing information to various key stakeholders on the progress and status of described programs/initiatives.
- Oversees the implementation of compliance policies and procedures to ensure that they meet organizations compliance requirements. Has management responsibility and accountability for the hospital's overall compliance with regulations from The Joint Commission, Department of Health Services, CMS and other regulatory agencies.
- Oversees the events, reporting, process, root cause analysis, and event investigation/review. Participates in system office initiatives and programs to mitigate risks identified at other hospitals resulting in reduced costs and adverse patient outcomes.
- Receives and oversees responses to patient complaints and investigates to solve issues promptly. Acts as an intermediary between patients, staff and family to provide clear communication between all parties regarding any outstanding issues.
