Program Manager, Quality, Safety & Regulatory

LE0030 Stanford Health Care Tri-Valley; Dublin (CA); On-site; USD 124,000 - 165,000; Full time

Job summary

Stanford Health Care Tri-Valley is seeking a Quality, Safety & Regulatory Program Manager to coordinate quality metrics, safety event follow-up, regulatory readiness, and infection prevention partnerships across OR, Cath Lab, Interventional Radiology, Endoscopy, SPD, Pre/Post, and related procedural services.

You will develop dashboards, track indicators, support corrective actions, and partner with leaders to sustain improvement and ensure compliance in a fast-paced procedural environment.

Qualifications

• Bachelor’s Degree required in nursing, healthcare administration, quality management, public health, clinical discipline, or related field.
• Master’s degree preferred.
• Minimum of four years of healthcare experience in quality, patient safety, regulatory readiness, perioperative/procedural services, infection prevention, nursing, or clinical operations.
• CPHQ, CPPS, CIC, or related quality/safety/regulatory certification preferred.
• Knowledge of healthcare quality, patient safety, regulatory standards, performance improvement, audit methods, and event follow-up.
• Ability to work independently, organize complex cross-functional work, and influence without direct authority.
• Strong data management, dashboard coordination, written communication, facilitation, and action-tracking skills.

Responsibilities

• Develop, maintain, and coordinate platform quality and safety dashboards for procedural areas.
• Track procedural quality indicators, infection prevention indicators, procedural complications, sedation events, radiation dose outliers, contrast events, unplanned transfers/admissions, retained item risks, specimen labeling defects, endoscope reprocessing compliance, sterilization indicators, and other measures.
• Prepare routine reports for the Monthly Procedural Quality and Safety Committee, Interventional Services Executive Council, and leadership review.
• Coordinate review, classification, follow-up, and closure tracking for procedural safety events, near misses, regulatory findings, and improvement actions.
• Support root cause analysis, apparent cause analysis, action planning, audit design, and evidence collection with Quality and Patient Safety partners.
• Ensure action plans have owners, timelines, evidence of completion, and sustainment measures.
• Coordinate procedural regulatory readiness activities, mock survey preparation, tracers, documentation audits, policy review, competency tracking evidence, and survey response support.
• Maintain readiness for surgical/procedural safety standards, sedation safety, high-level disinfection, infection prevention, radiation safety, contrast safety, medication safety, specimen handling, and SPD/sterilization processes.
• Partner with managers to identify gaps, elevate risks, and support timely corrective action.
• Support standardization of policies, procedures, checklists, audits, dashboards, and escalation pathways across procedural areas.
• Facilitate interdisciplinary improvement workgroups (sedation safety, verification, disinfection, infection prevention, radiation safety, SPD/OR).
• Promote a Just Culture, high-reliability principles, and transparent learning from events.

Skills

Healthcare quality

Patient safety

Regulatory standards

Performance improvement

Audit methods

Event follow-up

Data management

Dashboards

Written communication

Facilitation

Action tracking

Education

Bachelor's Degree in nursing, healthcare administration, quality management, public health, clinical discipline, or related field

Master’s degree preferred

Job description

If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered. Day - 08 Hour (United States of America) This is a Stanford Health Care Tri-Valley job.

A Brief Overview

The Quality, Safety & Regulatory Program Manager supports the Interventional and Procedural Services Platform by coordinating quality metrics, safety event follow-up, regulatory readiness, infection prevention partnership, radiation/contrast/sedation safety tracking, high-level disinfection oversight coordination, and procedural safety standards. Reporting to the Senior Director of Quality and PI, the Program Manager works closely with the VP of Interventional Services, Senior Director of Procedural Nursing and Clinical Operations, Platform Medical Director, specialty medical directors, managers, Quality, Patient Safety, Infection Prevention, Regulatory, Radiation Safety, Pharmacy, and other partners to ensure the platform has reliable quality infrastructure and visible accountability for improvement. This role is intended to be a central integration point for procedural quality, safety, and regulatory work. The Coordinator does not replace department-level accountability; rather, the role creates standard processes, dashboards, follow-up discipline, and escalation pathways across OR, Cath Lab, Interventional Radiology, Endoscopy, SPD, Pre/Post, and related procedural services.

Locations

Stanford Health Care Tri-Valley

What you will do

Quality Dashboard and Performance Monitoring

• Develop, maintain, and coordinate platform quality and safety dashboards for OR, Cath Lab, Interventional Radiology, Endoscopy, SPD, Pre/Post/PACU/Procedural Recovery, and related procedural services.
• Track procedural quality indicators, infection prevention indicators, procedural complications, sedation events, radiation dose outliers, contrast events, unplanned transfers/admissions, retained item risks, specimen labeling defects, endoscope reprocessing compliance, sterilization biological indicator failures, and other agreed measures.
• Prepare routine reports for the Monthly Procedural Quality and Safety Committee, Interventional Services Executive Council, and leadership review.

Safety Event Review and Corrective Action Coordination

• Coordinate review, classification, follow-up, and closure tracking for procedural safety events, near misses, regulatory findings, and improvement actions.
• Support root cause analysis, apparent cause analysis, action planning, audit design, and evidence collection in collaboration with Quality and Patient Safety partners.
• Ensure action plans have owners, timelines, evidence of completion, and sustainment measures.

Regulatory Readiness and Survey Support

• Coordinate procedural regulatory readiness activities, mock survey preparation, tracers, documentation audits, policy review, competency tracking evidence, and survey response support.
• Maintain readiness focus for surgical/procedural safety standards, sedation safety, high-level disinfection, infection prevention, radiation safety, contrast safety, medication safety, specimen handling, and SPD/sterilization processes.
• Partner with managers to identify gaps, elevate risks, and support timely corrective action.

Cross-Functional Improvement and Standardization Support

• Support standardization of policies, procedures, checklists, audits, dashboards, and escalation pathways across procedural areas.
• Facilitate interdisciplinary improvement workgroups as assigned, including sedation safety, procedural verification, high-level disinfection, infection prevention, radiation/contrast safety, and SPD/OR reliability.
• Promote a Just Culture, high-reliability principles, C-I-CARE, and transparent learning from events.

Key Performance Metrics

• Timeliness and completeness of quality dashboards, monthly reporting, action item closure, and sustainment audits.
• Safety event follow-up completion, corrective action verification, regulatory readiness scores, audit completion, and survey finding closure.
• Performance trends in sedation safety, radiation/contrast safety, infection prevention, retained item risk, specimen labeling defects, endoscope reprocessing compliance, sterilization monitoring, and procedural complications.
• Manager and physician leader satisfaction with quality reporting, escalation visibility, and improvement support.

Education Qualifications

• Bachelor's Degree in nursing, healthcare administration, quality management, public health, clinical discipline, or related field required.
• Master’s degree preferred.

Experience Qualifications

• Minimum of four (4) years of healthcare experience in quality, patient safety, regulatory readiness, perioperative/procedural services, infection prevention, nursing, or clinical operations.
• Experience with quality dashboards, safety event analysis, regulatory surveys, infection prevention, high-level disinfection, sedation safety, radiation or contrast safety, or procedural environments preferred.

License/Certification

• Clinical license preferred when applicable to candidate background.
• CPHQ, CPPS, CIC, or related quality/safety/regulatory certification preferred.

Required Knowledge, Skills and Abilities

• Knowledge of healthcare quality, patient safety, regulatory standards, performance improvement, audit methods, and event follow-up.
• Ability to work independently, organize complex cross-functional work, and influence without direct authority.
• Strong data management, dashboard coordination, written communication, facilitation, and action-tracking skills.
• Ability to maintain objectivity, confidentiality, and disciplined follow-through in sensitive quality and safety work.

These principles apply to ALL employees: SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery. You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Know Me: Anticipate my needs and status to deliver effective care
• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment.

Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above.

People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale

Generally starting at $59.50 - $79.33 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

Few great things are ever truly done alone. Performing at the highest level and achieving your best requires support and a team of dedicated people focused on doing amazing things every day. If that sounds like the environment you’ve been looking for, then we’ve got a place for you. Stanford Health Care - Tri-Valley is seeking outstanding allied health, business, and nursing professionals to join our world-class team. Supported by a devoted staff and a progressive culture, we offer the freedom, opportunity, and respect your talent deserves. Not every job offers this; but here, we don’t know how to work any other way. We invite you to join our team!