Job Description

Where Youll Work

Dignity Health Mercy San Juan Medical Center is a 384-bed not-for-profit Level 2 Trauma Center located in Carmichael California. We have served north Sacramento County as well as south Placer County for over 50 years. Our facility is one of the areas largest medical centers and also one of the most comprehensive. Our staff and volunteers are dedicated to community well-being; providing excellent patient care to all. Mercy San Juan Medical Center is a Comprehensive Stroke Center as well as a Spine Center of Excellence. We are proud recipients of the Perinatal Care Certificate of Excellence and a Certificate of Excellence for Hip and Knee Replacements.

Job Summary and Responsibilities

Full Time Day Quality and Patient Safety Program Manager

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 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.

The successful candidate will be familiar with improvement methods tools and techniques (e.g. PDSA Tests of Change Six Sigma LEAN) and the ability to create and support an environment that meets the quality goals of the organization along with Root cause analysis data reporting and familiarity with regulatory/accredidation requirements.

Job Requirements

Education and Experience:

• Bachelors 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 audits PI team member etc.) and three (3) years clinical experience in an acute care setting.

Licensure:

• 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 Experience:

Manager

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