Quality Patient Safety Program Manager - Licensed
Company: CommonSpirit Health
Location: Carmichael
Posted on: January 12, 2026
|
|
|
Job Description:
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. • 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. The successful candidate will be familiar with
improvement methods, tools and techniques (e.g. PDSA, Tests of
Change, Six Sigma, LEAN) and the ability to create and support an
environment that meets the quality goals of the organization, along
with Root cause analysis, data reporting and familiarity with
regulatory/accredidation requirements. Job Requirements 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. Where Youll Work Dignity Health
Mercy San Juan Medical Center is a 384-bed not-for-profit Level 2
Trauma Center located in Carmichael California. We have served
north Sacramento County as well as south Placer County for over 50
years. Our facility is one of the areas largest medical centers and
also one of the most comprehensive. Our staff and volunteers are
dedicated to community well-being; providing excellent patient care
to all. Mercy San Juan Medical Center is a Comprehensive Stroke
Center as well as a Spine Center of Excellence. We are proud
recipients of the Perinatal Care Certificate of Excellence and a
Certificate of Excellence for Hip and Knee Replacements.
Keywords: CommonSpirit Health, Newark , Quality Patient Safety Program Manager - Licensed, Healthcare , Carmichael, California
