Quality Patient Safety Program Manager Licensed

St. Joseph's Medical Center is a member of Dignity Health. The word dignity perfectly defines what our organization stands for showing respect for all people by providing excellent care. St. Joseph's Medical Center was founded in 1899 under the direction of the Dominican Sisters of San Rafael and is a not-for-profit fully-accredited regional hospital with 395 beds a physician staff of over 400 and more than 2400 employees. Specializing in cardiovascular care comprehensive cancer services and women and children's services including neonatal intensive care St. Joseph's is the largest hospital as well as the largest private employer in Stockton California. Nationally recognized as a quality leader St. Joseph's is consistently chosen as the most preferred hospital by local consumers.

One Community. One Mission. One California 

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.

• 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.

Education and Experience:

• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audits, PI team member, etc.).
• Three (3) years clinical experience in an acute care setting.
• Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction.

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.