Quality-Patient Safety Program Manager

Where You’ll Work

CHI Health Immanuel, located in North Omaha just off of I-680 on 72nd Street, offers a full-service hospital, cancer center, rehabilitation center, specialty spine hospital and more. For well over a century, our commitment to serve our community inspires our staff to provide the highest quality of care to all who we have the privilege to serve.

Job Summary and Responsibilities

CHI Health Immanuel will consider both licensed and non-licensed candidates for this position. Please note that the pay range will vary based on the candidate's licensure status.

 

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 patientsensitive and confidential hospital information.

 

 

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, patientexperience, 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 topublication.

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.

Job Requirements

Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting

Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction

One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.)

 

Current state license in a clinical field in state of practice.

Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate ofProfessional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

 

 

OR

 

Bachelor's degree or five (5) years of related job or industry experience in lieu of degree. One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.) and three (3) years clinical experience in an acute care setting. Certified Professional in Healthcare Quality (CPHQ), or HealthcareQuality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.