Quality-Patient Safety Program Mgr - Clinical Lic

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.

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.

Required

• three (3) years clinical experience in anacute care setting and
• One (1) year healthcare-related quality management/performanceimprovement experience (e.g., chart audit, PI team member, etc.) and
• Must be able to perform case reviews for medical staff peer reviewand medical and/or surgical Registry Abstraction
• Registered Nurse: KY, upon hire or
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• Certified Professional in Healthcare Quality, within 24 - months or
• Healthcare Quality Mgmt, within 24 - months or
• Cert Prof Healthcare Qual, within 24 - months or
• Registered Dietician, upon hire or
• Physical Therapist: KY, upon hire or
• Occupational Therapist: KY, upon hire or
• Speech Language Pathologist: KY, upon hire or
• Certified Respiratory Therapist, upon hire or
• Social Worker: KY, upon hire or
• Doctor of Medicine: KY, upon hire