CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.

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.

Required Education and Experience

Bachelor’s degree or higher in a clinical field and three (3) years

clinical experience in an acute care setting.
 One (1) year healthcare-related quality management/performance
improvement experience (e.g., chart audit, PI team member, etc.)

Required Licensure and Certifications 

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.

Required Minimum Knowledge, Skills, Abilities and Training

 Knowledge and expertise of quality management/performance
improvement methods, tools, and techniques (e.g. PDSA, Tests of
Change, Six Sigma, LEAN) and ability to create and support an
environment that meets the quality goals of the organization.
 Current knowledge of data reporting and regulatory/accreditation
requirements for acute and ambulatory care services and federal,
state and local healthcare related laws and regulations and the
ability to comply with these in healthcare practices and activities.
 Knowledge of effective self-management practices and ability to
manage multiple concurrent objectives, projects, groups, or
activities, making effective judgments as to prioritizing and time
allocation.
 Understanding of the necessity and value of accuracy and attention
to detail. Must be able to review patient records and provide case
summaries and maintain the confidentiality of the peer review
process.
 Knowledge of the techniques and the ability to work with a variety
of individuals and groups in a constructive and collaborative
manner.
 Knowledge of the current situation or issue at hand; ability to take
full personal responsibility or ownership for assignments, activities,
decisions and results.
 Knowledge of techniques and tools that promote effective analysis
and the ability to determine the root cause of organizational
problems and create alternative solutions that resolve the problems
in the best interest of the business.
 Ability to work well under pressure and respond to changing needs
and complex environments
 Excellent communication skills (oral and written), presentation
style, including the ability to concisely present data to leaders,
clinicians and staff at all levels of the organization