Manager Quality Patient Safety

• Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) 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
• Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures
• 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
• Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues
• Supports implementation of regulatory initiatives
• Oversees the events reporting process, root cause analysis, and event investigation/review
• Supports and encourages harm reporting throughout the organization through a non-punitive just event reporting system
• Participates in system office initiatives and programs to mitigate risks identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices/care
• Prepares and presents informative and actionable patient safety reports (to include patient's story of harm) to appropriate committees to include high level presentations to leadership, Medical Executive Committee and The Board
• Coordinates the requests from the system office claims team (related to litigated claims) and collaborates with other key stakeholders to implement learnings from claims
• Coordinates all legal documents related to hospital liability, including the management of subpoenas, Summons and Complaints and other related activities
• Educates and trains staff and physicians in quality improvement including the aggregation and analysis, action planning and reporting of performance data
• Provides patient safety education at new hire orientation and ongoing to leaders, clinician presentations (e.g. event reporting expectations, culture of safety, patient safety initiatives, etc.

• Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree
• Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization’s Quality Improvement Program including quality improvement methodology and data analysis
• Minimum of three (3) years of risk management, patient safety and/or other related professional experience
• Experience developing and implementing clinical, service and operational process improvement initiatives
• Minimum of two (2) years of clinical, patient care experience or equivalent
• Current state license in a clinical field
• 5 (five) years’ experience in Quality Management can be used in lieu of state license
• 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
• Knowledge and expertise in specific performance improvement/CQI methodologies (e.g. Six Sigma, LEAN)
• Current knowledge of data reporting and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations
• Joint Commission, etc.)
• Understands the importance of striving toward a zero defect goal and ability to establish methods and metrics that deliver targeted standards for products and services

medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings