Supervisory Responsibilities: Quality Department

Job Summary:

The Quality and Patient Safety Program Manager is responsible for developing, implementing, and evaluating the hospital's quality assessment and performance improvement (QAPI) program, and promoting a culture of safety and continuous improvement, including the skilled nursing facilities (SNFs), clinics, and ambulatory surgery center (ASC). This position plays a critical role in ensuring the delivery of high-quality, safe, and effective healthcare services to patients while driving continuous improvement in clinical processes, standards, and outcomes.

Duties/Responsibilities:

Quality Improvement Program Development:

o Develop, implement, and maintain the hospital's QAPI program, aligning with national and local

standards and best practices.

o Develop and implement quality improvement projects, using data analysis and evidence-based

practices.

o Coordinate and integrate QI plans and processes for individual services.

o Identify and implement process improvements to enhance efficiency, effectiveness, patient safety,

patient experience, and operational processes.

o Lead and participate in cross-functional teams to develop and execute quality improvement

initiatives.

o Foster a culture of continuous quality improvement by engaging clinical staff and leaders in quality-

related projects and initiatives.

· Data Analysis and Reporting:

o Collect, analyze, and interpret data related to quality and patient safety.

o Identify trends, patterns, and areas for improvement.

o Prepare and present reports on quality performance to hospital leadership and staff.

o Identify areas for improvement in clinical processes, patient care, and safety through data analysis

and regular assessments.

· Collaboration and Communication:

o Collaborate with hospital staff, physicians, and other healthcare professionals to improve quality and

patient safety.

Patient Safety:

o Promote a culture of safety within the hospital.

o Develop and implement strategies to address performance gaps and ensure consistent adherence to evidence-based clinical practices.

o Investigate and analyze adverse events and near misses.

o Develop and implement strategies to prevent adverse events.

· Other Responsibilities:

o Foster a positive and collaborative work environment that promotes teamwork, accountability, and coordination of quality improvement efforts. o Perform other duties as assigned.

Required Skills/Abilities:

Strong analytical, problem-solving, and decision-making skills.

· Proven record of accomplishment in leading successful quality improvement initiatives and achieving

measurable outcomes.

· Exceptional communication and interpersonal skills, with the ability to work effectively with diverse

stakeholders.

· Demonstrated leadership capabilities, including the ability to inspire, motivate, and develop a team.

· Proficiency in data analysis and reporting tools.

Education and Experience:

Bachelor’s degree in healthcare administration, nursing, medicine or a related field. Master’s degree

preferred

· Registered Nurse License (California), or one to three years of experience in a related clinical field required.

· Three to five years of experience in acute care hospital quality management required, with supervisory

experience a plus.

· Strong understanding of quality improvement methodologies, Microsoft Office, Incident Reporting, Peer

Review, Risk Management, OPPE/FPPE, QAPI regulatory requirements

· Professional certifications in quality management, patient safety, (e.g., CPHQ, CPPS) and knowledge of Lean/

Six Sigma principles are preferred.