Job Description

Quality Patient Safety Program Manager Clinical License

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Responsibilities

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Job Summary / Purpose

The primary function of the Quality/Patient Safety Program Manager Clinical License is to support, coordinate, and facilitate 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, handling patient-sensitive and confidential hospital information.

Essential Key Job Responsibilities

• Assist in designing, planning, implementing, and coordinating quality management, patient safety, and performance improvement activities for assigned hospital and medical staff departments, committees, divisions, service lines, and functions.
• Proactively coordinate and facilitate performance improvement teams supporting initiatives such as clinical quality improvement, patient safety, risk reduction, patient experience, efficiency, FMEAS, root cause analyses, and medical staff improvement (e.g., peer review case review, OPPE, FPPE).
• Participate in ensuring compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., including data collection and reporting of process and outcome measures.
• Develop and implement data collection tools and processes, identify necessary data elements, perform data collection and abstraction, validate data, and review reports prior to publication.
• Facilitate meetings, present data and reports, identify key findings, and assist with action plans and their implementation.
• Maintain current knowledge of accreditation and licensing requirements, serving as a resource to staff to improve outcomes and ensure compliance.
• Assist with regulatory readiness and survey preparation activities, including mock survey tracers.

Qualifications

Minimum Qualifications

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff with at least three (3) years of clinical experience in an acute care setting.
• Ability to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction.
• At least one (1) year of healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member).

Required Licensure and Certifications

• Current state license in a clinical field in the state of practice.
• Certified Professional in Healthcare Quality (CPHQ), Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment.

Overview

Dominican Hospital, part of Dignity Health, is a 222-bed facility offering comprehensive services including emergency care, cardiac, orthopedics, oncology, womens and childrens services. The hospital is recognized for patient safety and quality, with numerous awards and partnerships with Stanford Health Care, providing advanced neurological and endoscopic services.

Pay Range

$59.04 - $85.61 /hour

Additional Information

This position is full-time, in the field of Quality Assurance, within the healthcare and medical practice industries. It is not applicable to seniority level classifications.

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