Welcome to Saint Joseph Hospital, a 433-bed hospital founded in 1877 by the Sisters of Charity of Nazareth as the first Hospital in Lexington, Kentucky. Led by Sister Euphrasia Stafford, the mission to provide compassionate care to the poor and underserved is still carried out today. Saint Joseph Hospital holds over two dozen national ranks and recognitions and is recognized as a 2024 Best Place to Work in Kentucky.
Whether you are an experienced healthcare professional or working toward that, we invite you to experience Hello Humankindness with us! CHI Saint Joseph 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 such as:
*for eligible hires and positions
Learn more about Saint Joseph Hospital and its awards and recognitions here: Saint Joseph Hospital.
Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians advanced practice clinicians nurses and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2200 care centers serving 24 states.
JOB SUMMARY / PURPOSE
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.
The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.
Required Education and Experience
Required Licensure and Certifications
Required Minimum Knowledge, Skills, Abilities and Training
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