Quality Safety Risk Program Manager

Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. 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

JOB SUMMARY / PURPOSE

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.

Qualifications

Required Education and Experience

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, PI team member, etc.)

Required Licensure and Certifications

Quality and Management Certification (HCQM), or Certificate of

Professional Healthcare Quality and Patient Safety (CPQPS) within 2

years of employment is required.

Required Minimum Knowledge, Skills, Abilities and Training

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.

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.

manage multiple concurrent objectives, projects, groups, or

activities, making effective judgments as to prioritizing and time

allocation.

to detail. Must be able to review patient records and provide case

summaries and maintain the confidentiality of the peer review

process.

of individuals and groups in a constructive and collaborative

manner.

full personal responsibility or ownership for assignments, activities,

decisions and results.

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.

and complex environments

style, including the ability to concisely present data to leaders,

clinicians and staff at all levels of the organization