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The Regulatory and Patient Safety Manager in the Quality and Outcomes Management department is responsible for the coordination, consultation, educational and managing the operational activities of the patient safety program and the facility’s readiness for accreditation by The Joint Commission, Department of Health Services, or any other external accrediting bodies for Keck Medical Center of Company. This position is responsible for analyzing and preparing reports for clinical quality data as assigned to appropriate committee, participating in clinical event debriefs and facilitating development of action plans to address opportunities in outcomes related to sentinel and adverse events. Maintains a recognized area of expertise in regulatory standards and applies it in practice, teaching and consultation. Oversees investigations of patient safety events and root cause analysis as well as failure mode effects analysis. Manages QI/PI teams. Works collaboratively with management regarding quality and patient safety activities. Leads large system-wide change management efforts related to patient safety health system initiatives. Create, develop, and deliver change management strategy for complex projects. Additionally, the functions of this position includes supervision of staff and responsibility for reporting and presenting accurate, quality information both internally and externally utilizing specific criteria for abstraction. Vital components to this position are the identification of opportunities to improve care and outcomes.
Minimum Education: Bachelor’s degree in healthcare administration, nursing or related field required; Master’s (MHA, MBA) Degree or equivalent degree preferred. Minimum Experience/Knowledge: 5+ years of patient safety, risk management, quality improvement and/or direct patient care as an RN experience in an acute care hospital setting with at least 2-3 years in a lead/ supervisory role. Proficiency of both theoretical and practical aspects of patient safety including tools and techniques (formal project planning, risk/issue management, governance, cost/benefit analysis, project change controls, etc.) Experienced at least one facility-wide accreditation survey within the last three years. Working knowledge of Joint Commission, DHS, and Accreditation requirements. Management experience. Ability to facilitate working sessions with large, cross-functional, multidisciplinary teams Ability to present to and manage communication with quality and hospital executive leadership Ability to develop and present educational programs and/or workshops Ability to direct the development of programs/processes related to Quality Management and compliance with external regulatory and accreditation standards and requirements Knowledge of state and federal regulatory requirements related to healthcare compliance Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program Preferred Qualifications: Experience performing root cause analysis and FMEA Experience developing action plans related to patient safety events Working knowledge of quality improvement methodologies (PDCA, PDSA) Familiar with lean process improvement techniques: business (Six Sigma, total quality management) Proficiency with MS Office (Including Word, Excel, Outlook, PowerPoint, Access) Required License/Certification: Valid California Registered Nursing license required. CPHRM within 2 years, CPHQ or HACP certification within 2 years. Current registered nurse license if an RN. Fire and Safety Certification. If employee does not have card upon hire one must be obtained within 30 days of hire and maintained by renewal before expiration date.
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