Quality Patient Safety Program Manager Licensed

Marian Regional Medical Center, a 191-bed facility located in Santa Maria, California, is recognized as one of the Top 250 Hospitals in the Nation by Healthgrades and was awarded Best Maternity Care by Newsweek. It ranks among 10% in the nation for safety core measures in cardiac services and has the only comprehensive cancer treatment and resource program from Los Angeles to San Francisco. Marian’s beautiful mission-style facility houses the latest technology to support excellent physicians and caregivers who deliver compassionate care each and every day. Marian Regional Medical Center is a part of Dignity Health’s Southwest Division and is a member of CommonSpirit Health, the largest not-for-profit health care system in the nation, boasting an integrated network of top quality hospitals, with physicians from the most prestigious medical schools, and comprehensive outpatient services - all recognized for quality, safety, and service. Marian's offers Santa Maria Valley residents access to the most advanced technologies, an expanded and enhanced Emergency Department, Critical Care Unit, neonatal intensive care unit, and an array of women's services.

One Community. One Mission. One California 

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.

As a Quality Patient Safety Professional, you will develop, implement, and monitor programs to enhance patient safety and drive continuous quality improvement.

Every day you will conduct risk assessments, analyze adverse events, identify root causes, and recommend evidence-based strategies. You will also collaborate with clinical teams and regulators, providing education and guidance on best practices.

To be successful, you will demonstrate a comprehensive understanding of patient safety principles, quality improvement, and healthcare regulations. Your analytical skills, attention to detail, and ability to influence change will be crucial for fostering a culture of safety and achieving exceptional patient outcomes.

• 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.

*Reporting Structure may differ in Critical Access Hospitals

• Three (3) years clinical experience in an acute care setting
• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.)
• Must have at least one of the following Licenses:
  • Registered Nurse: CA (RN:CA)
  • Registered Nurse Practitioner: CA (RNP:CA)
  • Dietitian: CA (DIETITIAN:CA)
  • Pharmacist: CA (PHARM:CA)
  • Physical Therapist: CA (PT:CA)
  • Occupational Therapist: CA (OT:CA)
  • Speech Language Pathologist: CA (SLP:CA)
  • Medical Radiographer: CA (MRAD:CA)
  • Respiratory Care Practitioner: CA (RESP-LIC:CA)
  • Social Worker: CA (SWORKER:CA)
  • Doctor of Medicine: CA (MD:CA)
  • Doctor Osteopathic Medicine: CA (DO:CA)
• And one of the following certifications:
  • Certified Professional in Healthcare Quality (CPHQ)
  • Healthcare Quality Mgmt (HCQM)
  • Cert Prof Healthcare Qual (CPQPS)