Quality-Patient Safety Program Manager
About The Position
The Quality-Patient Safety Program Manager leads and coordinates hospital-wide and medical-staff Quality Management, Patient Safety, and performance improvement initiatives at CHI Health Creighton University Medical Center - Bergan Mercy. The role supports clinical excellence, organizational compliance, regulatory readiness, and a culture of continuous safety and improvement, applying requirements and standards including CMS HIQRP/HOQRP, TJC, and Leapfrog. The position facilitates multidisciplinary performance improvement teams, conducts clinical quality reviews and root cause analyses, identifies data elements, manages data collection and abstraction, and analyzes findings to produce actionable reports for leadership and clinical staff. It also serves as an internal consultant on accreditation requirements and oversees survey preparation activities, including mock tracers. The manager conducts case reviews for medical staff peer review and maintains strict confidentiality of peer review processes.
Requirements
- At least three years of clinical experience in an acute care setting.
- At least one year of healthcare-related quality management or performance improvement experience, such as chart audit or PI team participation.
- Active Registered Nurse (RN) or Pharmacist license at time of hire.
- Ability to perform case reviews for medical staff peer review.
- Experience with medical/surgical registry abstraction.
- Expertise in quality methodologies such as LEAN or Six Sigma.
- Exceptional analytical and communication skills.
- Ability to manage complex projects while maintaining strict confidentiality of peer review processes.
- Must obtain one of the following within 24 months of hire: Certified Professional in Healthcare Quality (CPHQ), Healthcare Quality Management (HCQM), or Certified Professional in Healthcare Quality (CPQPS).
Responsibilities
- Coordinate Quality Management, Patient Safety, and performance improvement initiatives across the hospital and medical staff.
- Facilitate multidisciplinary performance improvement teams.
- Conduct clinical quality reviews and root cause analyses to minimize risks and improve patient outcomes.
- Identify essential data elements and manage data collection and abstraction processes.
- Analyze findings and present actionable reports to leadership and clinical staff.
- Provide expert guidance as an internal consultant on accreditation requirements.
- Oversee survey preparation activities, including mock tracers.
- Perform case reviews for medical staff peer review.
- Maintain the strict confidentiality of peer review processes.
- Manage complex projects and support regulatory readiness and continuous improvement.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
No Education Listed
