**Overview**

**Dominican Hospital** (a member of Dignity Health) is a 222-bed facility that offers a wide range of services to residents of California’s Central Coast. With 24/7 emergency care comprehensive care in cardiac orthopedics oncology women’s and children’s services we continue to lead the region in medical innovation and excellence in healthcare. Comprehensive CareDominican offers emergency services and is a Certified Stroke Center and Chest Pain Center. Dominican’s services include the only comprehensive Cancer Center in Santa Cruz County a Total Joint Replacement program and advanced neurological and endoscopic services. Dominican regularly receives ‘A’ grades for hospital safety from Leapfrog Group and has received national recognition for superior patient safety cardiac care and stroke treatment from Healthgrades a leading provider of comprehensive information about physicians and hospitals.As Santa Cruz County’s heart attack (STEMI) receiving center Dominican Hospital provides cutting edge cardiac care. The hospital’s heart attack treatment times consistently beat the national average and the hospital offers two cardiac catheterization labs available 24 hours a day 7 days a week. Groundbreaking cardiac procedures at Dominican include the Transcatheter Aortic Valve Replacement (TAVR) procedure which allows for heart valve replacement without opening a patient’s chest.Dominican Hospital has forged significant partnerships with area hospitals to bring exceptional care to Santa Cruz County. The hospital offers a level III Neonatal Intensive Care Unit (NICU) through a partnership with Lucile Packard Children’s Hospital Stanford. Neurosurgery at Dominican is also offered through a partnership with Stanford Health Care.

**Responsibilities**

**SIGN-ON BONUS AND RELOCATION BONUS ELIGIBLE!**

**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.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

**Qualifications**

**MINIMUM QUALIFICATIONS:**

**Required Education:**

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

+ One (1) year healthcare-related quality management/performanceimprovement experience (e.g., chart audit, PI team member, etc.)Required Licensure and Certifications

**Required Licensure and Certifications:**

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

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

**Required Minimum Knowledge, Skills, Abilities and Training:**

+ Knowledge and expertise of quality management/performanceimprovement methods, tools, and techniques (e.g. PDSA, Tests ofChange, Six Sigma, LEAN) and ability to create and support anenvironment that meets the quality goals of the organization.

+ Current knowledge of data reporting and regulatory/accreditationrequirements for acute and ambulatory care services and federal,state and local healthcare related laws and regulations and theability to comply with these in healthcare practices and activities.

+ Knowledge of effective self-management practices and ability tomanage multiple concurrent objectives, projects, groups, oractivities, making effective judgments as to prioritizing and timeallocation.

+ Understanding of the necessity and value of accuracy and attentionto detail. Must be able to review patient records and provide casesummaries and maintain the confidentiality of the peer reviewprocess.

+ Knowledge of the techniques and the ability to work with a varietyof individuals and groups in a constructive and collaborativemanner.

+ Knowledge of the current situation or issue at hand; ability to takefull personal responsibility or ownership for assignments, activities,decisions and results.

+ Knowledge of techniques and tools that promote effective analysisand the ability to determine the root cause of organizationalproblems and create alternative solutions that resolve the problemsin the best interest of the business.

+ Ability to work well under pressure and respond to changing needsand complex environments

+ Excellent communication skills (oral and written), presentationstyle, including the ability to concisely present data to leaders,clinicians and staff at all levels of the organization

**Pay Range**

$59.04 - $85.61 /hour

We are an equal opportunity/affirmative action employer.