Quality Patient Safety Program Manager

Overview Saint Joseph London is a 150-bed regional hospital located in London Kentucky. Founded in 1926 Saint Joseph London opened a new $152 million 340000-square foot regional facility in 2010. We offer the latest technology along with nationally ranked award-winning services. Our patient rooms are private with most overlooking a small lake and garden on the 52-acre healing environment. Saint Joseph London treats patients from southeastern Kentucky including those from Clay Laurel Jackson Knox Pulaski Rockcastle and Whitley counties. CHI Saint Joseph Health supports 5000 active employees 8 hospitals specialty clinics and a Medical Group with more than 200 locations across Central and Eastern KY. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health in 2019. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community. 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. 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 (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. 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. Reporting Structure may differ in Critical Access Hospitals 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.