Quality Patient Safety Program Manager Licensed

Overview

Mercy Medical Center a Dignity Health member has been building a rich history of care in our community for more than 100 years. We have grown from a small one-story wooden structure into a major healthcare provider with a new 186-bed main campus offering the latest in facility design and technology. Mercy also operates Outpatient Centers a Cancer Center and several rural clinics.Wherever you work throughout our system you will find faces of experience with dedication to high quality personalized care. Joining our 1300 employees 230 physicians and many volunteers you can help carry out our commitment to providing our community with the excellence they have come to associate with Mercy Medical Center.

Responsibilities

Position Summary:

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.

Principal Duties and Accountabilities:

• Assists in the design, planning, implementation and coordination of QM, PS and PI 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, and root cause analyses and medical staff improvement (e.g. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review.

• 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.

Qualifications

Education and Experience:

• Bachelor's degree or five (5) years of related job or industry experience in lieu of degree.

• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audits, PI team member, etc.) and three (3) years clinical experience in an acute care setting.

Licensure:

• 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.