Quality-Patient Safety Program Manager - Clinical Lic

Carrington Health Center; Carrington (ND); On-site; USD 85,000 - 120,000; Full time

Job summary

CHI Carrington Health, now part of CommonSpirit Health, seeks a Quality-Patient Safety Program Manager to drive quality management, patient safety, and PI initiatives in an acute care setting.

You'll lead data-driven improvement projects, coordinate regulatory readiness, and partner with clinicians and leadership to enhance patient outcomes and safety culture.

Qualifications

• Licensed RN or other licensed clinical staff with 3 years acute care experience.
• Current state license in a clinical field.
• 1 year healthcare quality/performance improvement experience.
• CPHQ/HCQM/CPQPS certification within two years of employment.
• Case reviews for medical staff peer review and registry abstraction.

Responsibilities

• Design, plan, implement, and coordinate Quality Management, Patient Safety, and Performance Improvement activities.
• Coordinate performance improvement teams across initiatives (clinical quality, patient safety, patient experience, efficiency).
• Ensure regulatory compliance (CMS HIQRP/HOQRP, TJC, Leapfrog) with data collection and reporting of measures.
• Develop and implement data collection tools and processes (data elements, collection, validation).
• Facilitate meetings, present data, identify findings, and support action plans.
• Maintain knowledge of accreditation and licensing requirements and act as resource.
• Assist with regulatory readiness and mock survey tracers.

Skills

Nursing experience

Data analysis

Project management

Regulatory knowledge

Education

Registered Nurse license

CPHQ/HCQM/CPQPS certification within 2 years

Job description

Job Summary and Responsibilities

As our Quality-Patient Safety Program Manager, you'll lead ongoing quality improvement initiatives that collaborate with many healthcare professionals.

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.

Each day you'll make data-driven decisions to ensure our patients continuously receive high-quality care resulting in positive outcomes. In this clinical leadership role, you'll analyze data and implement different strategies for performance improvements, quality outcomes, risk reduction/mitigation, patient safety, and infection control, to name a few.

To be successful in this role, you'll apply your experience in nursing, operations, data analysis, and/or technology to build on our culture of continuous improvement. Your project management skills will ensure our teams continue moving forward with current initiatives.

What you'll do...

• Designs, plans, implements, and coordinates Quality Management, Patient Safety, and Performance Improvement (QI, PS, PI) activitiesfor assigned hospital and medical staff departments, committees, and service lines.
• Proactively coordinates and facilitates performance improvement teamsacross various initiatives, including:
  • Clinical quality improvement
  • Patient safety and risk reduction
  • Patient experience
  • Efficiency (e.g., FMEAs, root cause analyses)
  • Medical staff improvement (e.g., case review for peer review, OPPE, FPPE)
• Ensures compliance with regulatory requirements(e.g., CMS HIQRP/HOQRP, TJC, Leapfrog) regarding data collection and reporting of process and outcome measures.
• Facilitates development and implementation of data collection tools and processes, including:
  • Identifying necessary data elements.
  • Performing data collection and abstraction.
  • Validating data for submission or reporting.
• Facilitates meetings, presents data and reports, identifies key findings, and assists with action plansand implementation.
• Maintains current knowledge of accreditation and licensing requirementsand serves as a resource for staff on these regulations.
• Assists with regulatory readiness and survey preparation activities, including mock survey tracers.

Job Requirements

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting
• Current state license in a clinical field in the state of practice.
• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.)
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within two (2) years of employment is required.
• Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction.

Where You'll Work

CHI Carrington Health, now part of CommonSpirit Health formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health, have a variety of skills from clinical to project management. In our Critical Access Hospital, you will be exposed to the emergency department, acute care (Med/Surg), swing bed, surgery, outpatient treatment, and so much more!