Quality and Patient Safety Program Manager Licensed
Quality and Patient Safety Program Manager Licensed
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Salary Not Disclosed
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Job Description
Where Youll Work
Dignity Health @ Mercy Hospital of Folsom is the community hospital serving the Sierra foothills communities of Folsom El Dorado Hills Granite Bay Cameron Park Shingle Springs and Rescue. With 106 licensed acute-care beds our accredited non-profit hospital has been providing exceptional care for more than 35 years. Mercy Hospital of Folsom provides surgical services including minimally-invasive general urological and gynecological surgeries. We also provide comprehensive and award-winning orthopedic services which include surgery inpatient and outpatient rehabilitation and specialty orthopedic care. As a certified Joint Commission Stroke Center Mercy Folsom provides exceptional care to our patients in our Medical Surgical and Intensive Care units as well as our 25-bed Emergency Department. Our Family Birth Center features private and contemporary birthing suites where labor delivery and recovery occur in one room as well as award-winning lactation training and support. Mercy Folsom received Among Americas 250 Best Hospitals recognition and is a Primary Stroke Center.
Job Summary and Responsibilities
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.
- 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. Assists with regulatory readiness and survey preparation activities including mock survey tracers.
Job Requirements
Minimum Required
- 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.)
- Current state license in a clinical field in California
- 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.
Skills / Knowledge
- 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
