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Quality-Patient Safety Program Mgr - Clinical Lic - job 1 of 2

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Overview

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:

Paid Time Off (PTO)
401(k) and 457(b) Retirement Programs with matching
Medical/Dental/Vision Insurance
Mental Health resources for you and your family
Wellness Program with rewards up to $450
Tuition Reimbursement for future career growth and development
Adoption Assistance
Voluntary Protection: Accident, Critical Illness, Identify Theft and Pet Insurance
Short and Long Term Disability
Free Premium Membership to Care.com with preloaded credits to support adult and child care needs
Employer Discounts
Relocation Assistance*
Employee Referral Bonuses up to $7,500*

*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.

Responsibilities

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.

ESSENTIAL KEY JOB RESPONSIBILITIES

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.

Qualifications

MINIMUM QUALIFICATIONS

Required Education and Experience

Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and 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
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.
Understanding of the necessity and value of accuracy and attention to detail. Must be able to review patient records and provide case summaries and maintain the confidentiality of the peer review process.
Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
Knowledge of the current situation or issue at hand; ability to take full personal responsibility or ownership for assignments, activities, decisions and results.
Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions that resolve the problems in the best interest of the business.
Ability to work well under pressure and respond to changing needs and complex environments
Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization

Average salary estimate

$70000 / YEARLY (est.)

min

max

$60000K

$80000K

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What You Should Know About Quality-Patient Safety Program Mgr - Clinical Lic, UNAVAILABLE

At Saint Joseph Hospital, we're looking for a dedicated Quality-Patient Safety Program Manager to join our clinical team in Lexington. Since our founding in 1877, our mission has always been about providing compassionate care, and this role is key to achieving that. As the Quality-Patient Safety Program Manager, you will spearhead initiatives focused on improving quality management, patient safety, and regulatory performance. Your insights will help set the tone for critical performance improvement activities, guiding teams and departments towards excellence in healthcare delivery. Your responsibilities will include coordinating performance improvement teams, participating in case reviews, and ensuring compliance with national standards like CMS HIQRP and TJC. You will be the go-to resource for employees and management on quality management activities, and your knowledge will directly impact patient care. Your background as a licensed clinical professional, combined with your experience in quality management, will contribute to making our hospital a safer and more effective environment for both staff and patients. We truly believe in the importance of work/life balance and provide a supportive benefits package including tuition reimbursement, wellness programs, and even adoption assistance. If you’re passionate about making a difference in people’s lives through quality healthcare, then we’d love to have you become part of our Saint Joseph Hospital family.

Frequently Asked Questions (FAQs) for Quality-Patient Safety Program Mgr - Clinical Lic Role at UNAVAILABLE

What are the primary responsibilities of a Quality-Patient Safety Program Manager at Saint Joseph Hospital?

As a Quality-Patient Safety Program Manager at Saint Joseph Hospital, your primary responsibilities include supporting, coordinating, and facilitating quality management and patient safety activities. You will design, implement, and coordinate performance improvement initiatives, assist in compliance with accreditation standards, and ensure staff at all levels are knowledgeable about quality management efforts.