Job Description

**Responsibilities** 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. **Principal Duties and Accountabilities:** + Assists in the design, planning, implementation and coordination of Quality Mgmt., 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, and root cause analyses and medical staff improvement (e.g. 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. + Directors programs involving risk mitigation/management and initiatives related to providing safer care to patients. This position is responsible for providing information to various key stakeholders on the progress and status of described programs/initiatives. + Oversees the implementation of compliance policies and procedures to ensure that they meet organization's compliance requirements. Has management responsibility and accountability for the hospitals' overall compliance with regulations from The Joint Commission Department of Health Services CMS and other regulatory agencies. + Oversees the events reporting process root cause analysis and event investigation/review. Participates in system office initiatives and programs to mitigate risks identified at other hospitals resulting in reduced costs and adverse patient outcomes. + Receives and oversees responses to patient complaints and investigates to solve issues promptly. Acts as an intermediary between patients staff and family to provide clear communication between all parties regarding any outstanding issues **Qualifications** + Bachelor's degree, or five (5) years of related job or industry experience in lieu of degree + 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 of Professional Healthcare Quality and Patient Safety (CPQPS) within two (2) years of employment is required. + One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audits, PI team member, etc.) + Three (3) years clinical experience in an acute care setting **Overview** Founded in 1887 Dignity Health - California Hospital Medical Center is a 392-bed acute care nonprofit hospital located in downtown Los Angeles. The hospital offers a full complement of services including a Level II trauma center the Los Angeles Center for Womens Health obstetrics and pediatric services and comprehensive cardiac and surgical services. The hospital shares a legacy of humankindness with Dignity Health one of the nations five largest health care systems. Visit for more information. **Pay Range** $51.44 - $74.58 /hour We are an equal opportunity/affirmative action employer.

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