Quality-Patient Safety Program Manager

At CHI Health Creighton University Medical Center - Bergan Mercy, our focus is patient-centered care. Our level I trauma center and academic medical center campus is designed to heal the body, mind, and spirit of every person in a more comfortable, less stressful hospital environment. Our full range of medical services includes trauma services, heart and vascular care, emergency services, surgery, maternity, cancer care, and diagnostic imaging.

As our Quality-Patient Safety Program Manager, you will serve as a vital leader in driving clinical excellence and organizational compliance. You will be responsible for coordinating comprehensive Quality Management (QM), Patient Safety (PS), and performance improvement initiatives across the hospital and medical staff. By leveraging your expertise in healthcare regulations—such as CMS HIQRP/HOQRP, TJC, and Leapfrog standards—you will ensure the facility maintains peak performance, regulatory readiness, and a culture of continuous safety and improvement.

Every day you will facilitate multidisciplinary performance improvement teams, conduct clinical quality reviews, and perform root cause analyses to minimize risks and enhance patient outcomes. Your role involves identifying essential data elements, managing data collection and abstraction processes, and analyzing key findings to present actionable reports to leadership and clinical staff. You will act as a key internal consultant, providing expert guidance on accreditation requirements and overseeing survey preparation activities, including mock tracers, to ensure the highest standards of healthcare delivery.

To be successful in this role, you will possess at least three years of clinical experience in an acute care setting, paired with one year of specialized experience in healthcare quality management or performance improvement. We require candidates to hold an active license as a Registered Nurse or Pharmacist and a commitment to earning a CPHQ or HCQM certification within 24 months. You must be an expert in quality methodologies like LEAN or Six Sigma, demonstrate exceptional analytical and communication skills, and have the ability to manage complex projects while maintaining the strict confidentiality of peer review processes.

Education and Experience

• Clinical Experience: Minimum of three (3) years of clinical experience in an acute care setting.
• Quality Management: Minimum of one (1) year of healthcare-related quality management or performance improvement experience (e.g., chart audit, PI team participation).
• Technical Skills: Proven ability to perform case reviews for medical staff peer review and experience with medical/surgical registry abstraction.

Licensure and Certifications

• Professional License: Must hold an active Registered Nurse (RN) or Pharmacist license (at time of hire).
• Required Certifications: Must obtain one of the following within 24 months of hire:
  • Certified Professional in Healthcare Quality (CPHQ)
  • Healthcare Quality Management (HCQM)
  • Certified Professional in Healthcare Quality (CPQPS)