Quality and Patient Safety Program Manager

Overview

Since 1885, CHI St. Alexius Health has been dedicated to leading health care in this region by enriching the lives of patients through the highest quality of care. We seek to continue our tradition of success and innovation with individuals dedicated to delivering the highest level of expertise and quality. Together we can continue to grow and support the legacy of CHI St. Alexius Health for many years to come.

CHI St. Alexius Health is a regional health network with a tertiary hospital in Bismarck, the system also consists of critical access hospitals (CAHs) in Carrington, Dickinson, Devils Lake, Garrison, Turtle Lake, Washburn and Williston and numerous clinics and outpatient services. CHI St. Alexius Health manages four CAHs in North Dakota - Elgin, Linton, and Wishek, as well as Mobridge Regional Medical Center in Mobridge, S.D. CHI St. Alexius Health offers a comprehensive line of inpatient and outpatient medical services, including: a Level II Trauma Center, primary and specialty physician clinics, home health and hospice services, durable medical equipment services, a fitness and human performance center and ancillary services throughout western and central North Dakota.

CHI St. Alexius Health is part of CommonSpirit Health, a nonprofit, Catholic health system dedicated to advancing health for all people. It was created in February 2019 through the alignment of Catholic Health Initiatives and Dignity Health. CommonSpirit Health is committed to creating healthier communities, delivering exceptional patient care, and ensuring every person has access to quality health care.

We offer the following benefits to support you and your family:

• Employee Assistance Program (EAP) for you and your family
• Health/Dental/Vision Insurance
• Flexible spending accounts
• Voluntary Protection: Group Accident, Critical Illness, and Identity Theft
• Adoption Assistance
• Paid Time Off (PTO)
• Tuition Assistance for career growth and development
• Matching Retirement Programs
• Wellness Program

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.

Qualifications

Required Education and Experience

• Bachelor's degree or higher in a clinical field and three (3) years clinical experience in an acute care setting.
• 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(RN, PT, RT, OT etc) in state of practice REQUIRED .
• 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,

• 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