Job Abstract

Founded in 1926 Glendale Memorial Hospital and Health Center is a 334-bed acute care nonprofit community hospital located in Glendale California. The hospital offers a full complement of services including its award winning heart center the colorectal surgery institute a gastrointestinal program and is a Los Angeles County approved primary stroke center. The hospital shares a legacy of humankindness with Dignity Health one of the nation’s five largest health care systems. Visit https://www.dignityhealth.org/socal/locations/glendalememorial for more information.

Job Summary: 

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.

• 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 organizations 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
• Assists in the design, planning, implementation and coordination of QM, PS and PI 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. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review.
• 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.

Education and Experience:

• Bachelors 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 audits, PI team member, etc.) and three (3) years clinical experience in an acute care setting.

Licensure:

• 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 2 years of employment is required.