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Form of workAt CHI Health Mercy Council Bluffs patients are at the heart of our care. Our campus is designed to heal the body mind and spirit of every person in a more comfortable less stressful hospital environment. Our full range of medical services include a new pavilion featuring enhancements in heart and vascular care surgery maternity cancer care and diagnostic imaging.
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.
Licensed Registered Nurse, Licensed Clinical Pharmacist, or
other Licensed Clinical Staff and three (3) years clinical
experience in an acute care setting
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.
Must be able to perform case reviews for medical staff peer
review and medical and/or surgical Registry Abstraction
One (1) year healthcarerelated quality
management/performance improvement experience (e.g.,
chart audit, PI team member, etc.)
