Quality-Patient Safety Program Mgr - Clinical Lic
Quality-Patient Safety Program Mgr - Clinical Lic
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1 Vacancy
Job Description
Overview
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-prot Catholic health system dedicated to advancing health for all people. With approximately 175000 employees and 25000 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 2200 care centers serving 24 states.
Responsibilities
JOB SUMMARY / PURPOSE
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.
ESSENTIAL KEY JOB RESPONSIBILITIES
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 specifically with peer reviews.
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.
The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.
Qualifications
MINIMUM QUALIFICATIONS
Required Education and Experience
- Licensed Registered Nurse Licensed Clinical Pharmacist or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting
- Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction
- One (1) year healthcare-related quality management/performance improvement experience (e.g. chart audit PI team member etc.)
Required Licensure and Certifications
- Current state license in a clinical field in state of practice.
- Certified Professional in Healthcare Quality (CPHQ) or Healthcare Quality and Management Certification (HCQM) or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Required Minimum Knowledge Skills Abilities and Training
- Knowledge and expertise of quality management/performance improvement methods tools and techniques (e.g. PDSA Tests of Change Six Sigma LEAN) and ability to create and support an environment that meets the quality goals of the organization.
- Current knowledge of data reporting and regulatory/accreditation requirements for acute and ambulatory care services and federal state and local healthcare related laws and regulations and the ability to comply with these in healthcare practices and activities.
- Knowledge of effective self-management practices and ability to manage multiple concurrent objectives projects groups or activities making effective judgments as to prioritizing and time allocation.
- Understanding of the necessity and value of accuracy and attention to detail. Must be able to review patient records and provide case summaries and maintain the confidentiality of the peer review process.
- Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
- Knowledge of the current situation or issue at hand; ability to take full personal responsibility or ownership for assignments activities decisions and results.
- Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions that resolve the problems in the best interest of the business.
- Ability to work well under pressure and respond to changing needs and complex environments
- Excellent communication skills (oral and written) presentation style including the ability to concisely present data to leaders clinicians and staff at all levels of the organization
Required Experience:
Manager
Employment Type
Unclear
