Overview
CHI Memorial Hospital, now part of CommonSpirit Health formed between Catholic Health Initiatives (CHI) and Dignity Health, is once again the only hospital in the Chattanooga area to be named a Best Regional Hospital by U.S. News & World Report. We are proud to be the regional referral center of choice providing health care throughout Southeast Tennessee and North Georgia.
We offer the following benefits to support you and your family:

• On-site childcare with extended hours
• Care@Work premium account for additional support with children, pets, dependent adults, and household needs
• Employee Assistance Program (EAP) for you and your family
• Paid Time Off (PTO)
• Health/Dental/Vision Insurance
• Flexible spending accounts
• Voluntary Protection: Group Accident, Critical Illness, and Identify Theft
• Adoption Assistance
• Tuition Assistance for career growth and development
• Matching 401(k) and 457(b) Retirement Programs
• Wellness Program
• Additional incentives for eligible full time day shift and night shift opportunities

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.
Qualifications

• Bachelor's degree or higher in a clinical field and three (3) years clinical experience in an acute care setting.
• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, Pl team member, etc.)
• 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.