Quality Patient Safety Program Manager - CommonSpirit Health

CHI Williston Health now part of CommonSpirit Health formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health have a variety of skills from clinical to project management. In our Critical Access Hospital you will be exposed to the emergency department acute care (Med/Surg) swing bed surgery outpatient treatment and so much more! CHI Williston Health provides you with the same level of care you provide for others. We care about our employees well-being and offer benefits that complement work/life balance.

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

WHAT YOU WILL BE DOING:

• Assists in the design, planning, implementation and coordination of QM, PS and PI 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. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review.
• 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.

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
•  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 and expertise of quality management/performance
  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.
•  Current knowledge of data reporting and regulatory/accreditation
  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.
•  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.