Job Summary and Responsibilities
As our Licensed Quality Patient Safety Program Manager, you will serve as a vital resource for hospital leadership, medical staff, and clinical teams, driving excellence in quality management and patient safety initiatives. This pivotal role is responsible for coordinating performance improvement (PI) strategies, ensuring regulatory compliance with organizations such as TJC and CMS, and fostering a culture of safety. You will leverage your expertise in quality management tools to reduce risk, enhance patient experience, and facilitate data-driven decision-making across all service lines.
Every day you will lead performance improvement efforts, including root cause analyses, FMEA processes, and medical staff peer reviews. You will be responsible for the end-to-end data lifecycle—from identifying necessary data elements and performing meticulous abstraction to validating outcomes for regulatory reporting. Beyond data, you will facilitate collaborative meetings, present key findings to stakeholders, and develop actionable plans that translate clinical insights into improved patient outcomes and hospital-wide compliance readiness.
To be successful in this role, you will possess at least three years of acute care clinical experience and a minimum of one year in healthcare-related quality management or performance improvement. You must hold an active, applicable clinical license (such as RN, RNP, Pharmacist, PT, or MD/DO) and demonstrate mastery in PI methodologies like Six Sigma or LEAN. Expert communication skills, the ability to interpret complex federal and state healthcare regulations, and a proven track record of managing concurrent projects under pressure are essential to driving high-level organizational success.
Job Requirements
Required:
- Three (3) years clinical experience in an acute care setting, and
- One (1) year healthcare related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.).
- Registered Nurse: AZ (RN:AZ) or
- Physical Therapist AZ or
- Occupational Therapist AZ, and
- Certified Professional in Healthcare Quality (CPHQ) within 24 months, or
- Healthcare Quality Management (HCQM) within 24 months
- 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.
