Quality-Patient Safety Program Manager - Clinical Lic

Responsible for the implementation and management of the Performance Improvement (PI) plan, the facility Patient Safety Program, including the Patient Safety Plan, and ensuring and maintaining compliance with The Joint Commission and relevant State and Federal regulations related to accreditation and regulatory requirements, quality monitoring and performance improvement. Participates in system office quality and patient safety initiatives and programs.

• Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) 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.
  
• Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
  
• 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. Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues. Supports implementation of regulatory initiatives.
  
• Oversees the events reporting process, root cause analysis, and event investigation/review. Supports and encourages harm reporting throughout the organization through a non-punitive just event reporting system. Participates in system office initiatives and programs to mitigate risks identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices/care. Prepares and presents informative and actionable patient safety reports (to include patient's story of harm) to appropriate committees to include high level presentations to leadership, Medical Executive Committee and The Board.

Required

• Bachelors Other, in a healthcare-related field OR five (5) years of related job or industry experience in lieu of degree.
• Minimum of three (3) years of progressive management responsibility in an acute care setting
  • one (1) of which is related to managing an organization’s Quality Improvement Program including quality improvement methodology and data analysis
  • Minimum of three (3) years of risk management, patient safety and/or other related professional experience
• Experience developing and implementing clinical, service and operational process improvement initiatives
• Minimum of two (2) years of clinical, patient care experience or equivalent

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 team members' well-being and offer benefits that complement work/life balance.