Quality Patient Safety Program Manager Licensed - CommonSpirit Health

Dominican Hospital (a member of Dignity Health) is a 222-bed facility that offers a wide range of services to residents of California’s Central Coast. With 24/7 emergency care comprehensive care in cardiac orthopedics oncology women’s and children’s services we continue to lead the region in medical innovation and excellence in healthcare. Comprehensive CareDominican offers emergency services and is a Certified Stroke Center and Chest Pain Center. Dominican’s services include the only comprehensive Cancer Center in Santa Cruz County a Total Joint Replacement program and advanced neurological and endoscopic services. Dominican regularly receives ‘A’ grades for hospital safety from Leapfrog Group and has received national recognition for superior patient safety cardiac care and stroke treatment from Healthgrades a leading provider of comprehensive information about physicians and hospitals.As Santa Cruz County’s heart attack (STEMI) receiving center Dominican Hospital provides cutting edge cardiac care. The hospital’s heart attack treatment times consistently beat the national average and the hospital offers two cardiac catheterization labs available 24 hours a day 7 days a week. Groundbreaking cardiac procedures at Dominican include the Transcatheter Aortic Valve Replacement (TAVR) procedure which allows for heart valve replacement without opening a patient’s chest.Dominican Hospital has forged significant partnerships with area hospitals to bring exceptional care to Santa Cruz County. The hospital offers a level III Neonatal Intensive Care Unit (NICU) through a partnership with Lucile Packard Children’s Hospital Stanford. Neurosurgery at Dominican is also offered through a partnership with Stanford Health Care.

Position Summary

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.

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, and root cause analyses and medical staff improvement (e.g. 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.

Education and Experience:

• Bachelor's degree or five (5) years of related job or industry experience in lieu of degree.

• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.) and three (3) years clinical
  experience in an acute care setting.

Licensure:

• 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.