Program Manager- Quality and Patient Safety, Ambulatory Quality - Trinity Health System

POSITION TITLE:

Qualityand Patient Safety Program Manager, Ambulatory Quality Management systems

POSITION SCOPE:

System

System or Division

System

Date Last Updated

April 6, 2021

Functional Area

Quality/Patient Safety Program Manager

Reports To

Market Director, Ambulatory Quality

FLSA Status

EXEMPT in accordance w/FLSA Regs

Supervisory Responsibility

NO

Job Code

Travel Frequency

Light 0-25%

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 Physician Enterprise. This role also serves as a resource to employees, management, directors, senior management, councils, physicians and teams on quality management activities and will handle patient sensitive and confidential hospital information.

• Assists in the design, planning, implementation and coordination of QM, PS and PI activities for Physician Enterprise 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 ambulatory and 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 data reporting requirements (eg. MIPS), 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

Minimum Qualifications

Required Education and Experience

One (1) year healthcare-related quality management/performance. Bachelor’s degree or five (5) years of related job or industry experience in lieu of degree.

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.

Required Minimum Knowledge, Skills, Abilities and Training

• Knowledge of effective self-management practices and ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Understanding of the necessity and value of accuracy and attention to detail; ability to process information with high levels of accuracy.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Knowledge of major functional processes and associated operating requirements; ability to apply this knowledge appropriately to diverse situations.
• Knowledge of the current situation or issue at hand; ability to take full personal responsibility or ownership for assignments, activities, decisions and results.
• Demonstrates breadth and/or depth of professional/technical skills and capabilities required for position; shares knowledge; sets or contributes to the Company’s direction within area of expertise.
• Keeping the organization’s mission, vision and values at the forefront of associate decision making and action.
• Ensuring that the patient/customer perspective is a driving force behind our actions and business decisions; crafting and implementing service practices that meet patients'/customer's and own organization’s needs. (Focus also includes internal and external customers.)
• Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
• Knowledge of the critical interdependencies among system elements that help and hinder performance and ability to plan and design solutions that synchronize resources to achieve business results.
• Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities.
• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks.
• Knowledge of purpose and impact of The Joint Commission; to continuously improve the healthcare for the public, in collaboration with other stakeholders, by evaluating health care providers and inspiring them to excel in providing safe and effective care at the highest quality and value and the Center for Medicare and Medicaid Services (CMS). This also includes (PTAC) Professional Technical Advisory Committees.
• Knowledge of techniques and tools that promote effective analysis 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.

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