Quality-Patient Safety Program Manager - Clinical Licensed

CHI Carrington Health, now part of CommonSpirit Health formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health, have a variety of skills from clinical to project management. In our Critical Access Hospital, you will be exposed to the emergency department, acute care (Med/Surg), swing bed, surgery, outpatient treatment, and so much more!

As our Quality-Patient Safety Program Manager, you'll lead ongoing quality improvement initiatives that collaborate with many healthcare professionals.

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.

Each day you'll make data-driven decisions to ensure our patients continuously receive high-quality care resulting in positive outcomes. In this clinical leadership role, you'll analyze data and implement different strategies for performance improvements, quality outcomes, risk reduction/mitigation, patient safety, and infection control, to name a few. 

To be successful in this role, you'll apply your experience in nursing, operations, data analysis, and/or technology to build on our culture of continuous improvement. Your project management skills will ensure our teams continue moving forward with current initiatives. 

What you'll do...

• Designs, plans, implements, and coordinates Quality Management, Patient Safety, and Performance Improvement (QI, PS, PI) activities for assigned hospital and medical staff departments, committees, and service lines.
• Proactively coordinates and facilitates performance improvement teams across various initiatives, including:
  • Clinical quality improvement
  • Patient safety and risk reduction
  • Patient experience
  • Efficiency (e.g., FMEAs, root cause analyses)
  • Medical staff improvement (e.g., case review for peer review, OPPE, FPPE)
• Ensures compliance with regulatory requirements (e.g., CMS HIQRP/HOQRP, TJC, Leapfrog) regarding data collection and reporting of process and outcome measures.
• Facilitates development and implementation of data collection tools and processes, including:
  • Identifying necessary data elements.
  • Performing data collection and abstraction.
  • Validating data for submission or reporting.
• 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 serves as a resource for staff on these regulations.
• Assists with regulatory readiness and survey preparation activities, including mock survey tracers.

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting
• Current state license in a clinical field in the state of practice.
• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.)
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within two (2) years of employment is required.
• Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction.