Req#: 14855
Full Time, Day Shift M-F 8-5p
The Quality and Patient Safety Program Manager plays a vital leadership role in advancing the hospital’s mission to deliver safe, effective, patient‑centered care. This position is responsible for managing key quality and safety program initiatives including, but not limited to, quality and safety event reporting and investigation, clinical performance improvement, quality and safety data management, support of clinical quality programs, Leapfrog and Culture of Safety survey management. Reporting to the Senior Director of Quality and Patient Safety, the Manager supports the design, execution, and monitoring of quality and patient safe care.
Requirements:
Responsibilities:
1. Maintains current knowledge of Board of Registration in Medicine (BRM), DHHS, DNV, CMS, and other regulatory standards and regulations and disseminates information to the appropriate individuals.
2. Actively reviews and engages with BILH quality and safety event reporting system. Responsible for the support and triage of events with respect to quality, safety and professional practice review. Instrumental in the visibility and reporting of trends from the event reporting system to senior leadership.
3. Leads quality and patient safety committees as assigned by the Senior Director of Quality, Patient Safety and Risk (e.g. Patient Safety Commitee). Facilitates intensive review of significant clinical adverse events. Analyzes data utilizing informal and formal analytical methodology such as Root Cause Analysis, Common Cause Analysis and Failure Mode and Effects Analysis. Track and ensure timely implementation and effectiveness validation of corrective actions. Recommends specific actions to eliminate or mitigate the risk of patient harm. Completes documentation of all such reviews ensuring audit and survey readiness for relevant events. A highly interprofessional and interdependent function of the role.
4. Regulatory Internal Audit Program Lead: Design, implement, and maintain a comprehensive internal audit program aligned with DNV, CMS, and other relevant regulatory standards; Coordinate internal audits of National Integrated Accreditation for Healthcare Organizations (NIAHO) chapters and ISO 9001 requirements; Maintain audit tracking tools and dashboards to monitor audit status, findings, and outcomes; In the support of accreditation and working closely with accreditation lead, the position will lead internal audit teams, facilitate findings debriefs, and support departments in action planning and loop closure. Support documentation, follow‑up, and process improvement activities related to risk management findings and accreditation readiness.
5. Quality and Safety Data Management: Support the development, implementation, and evaluation of the hospitals Quality and Patient Safety Plan. Serve as a liaison to departmental quality leaders and teams, promoting consistent use of quality tools, data, and evidence‑based practices. Monitor and trend clinical quality and safety indicators; analyze data to identify risks and opportunities. Support the development of quality dashboards, scorecards, and performance reports for committees and leadership. Ensure timely escalation of risks or gaps to the Senior Director and other leaders.
6. Gathers data from internal and external data services to establish benchmarks and gather information on lessons learned from local, regional, and national patient safety initiatives.
7. Leapfrog Survey and Regulatory Readiness: Lead the data collection, validation, and submission of the Leapfrog Hospital Survey and Hospital Safety Grade. Coordinate with operational and clinical stakeholders to meet survey standards and improve performance. Assist in regulatory readiness including mock surveys, policy compliance audits, and regulatory education.
8. Culture of Safety and High Reliability: Promote a strong culture of safety through staff education, leadership rounding, and Just Culture principles. Assist in developing and monitoring safety culture survey action plans (e.g., AHRQ SOPS). Partner with Human Resources and Risk on workforce engagement in safety learning and coaching programs.
9. Supports clinical quality programs including but not limited to, Stroke, Trauma, NSQIP. Partner in quality compliance for other aspirational accreditation and certification work.
10. Performs other duties as assigned.
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