Job Summary: The Quality and Patient Safety Manger--Safety (PS Manager) is responsible for enhancing the safety and quality of clinical care processes. The PS Manager oversees the operations of the Patient Safety section of the Quality and Patient Safety (QPS) Department and ensures all department activities are in compliance with NCQA, IMQ and health plan standards and in alignment with Sutter Health, Bay Area Operating Unit, PAMF, MPMG and SMSC objectives. The PS Manager also must understand the work of, collaborate with and provide cross coverage for the Quality Manager within the QPS department. The PS Manager promotes a culture that perceives quality and safety of care as foundational and ensures that all information, data, analytics generated through the department supports progress in these areas. The PS Manager facilitates regulatory compliance and accreditation readiness within PAMF, MPMG and SMSC as applicable and appropriate. Key areas of oversight include, but are not limited to, the ambulatory and inpatient Patient Safety and Infection Control and Prevention programs as well as the ambulatory medication and medical device recall program.
Implement quality and safety standards set by the system at PAMF, SMSC and MPMG
- Improve the quality and safe delivery of patient care by enhancing clinical and partner with internal/external stakeholders in the design and execution of quality improvement, patient safety and harm reduction interventions for these patient populations.
- Maintain, improve, develop and disseminate programs to improve and enhance QPS department efficiencies and effectiveness.
- Ensure quality and safety issues are identified and effectively addressed.
- Work with operations, quality, risk, and physician leadership locally and at the operating unit and system levels to deploy evidence based, patient centered and safe processes and to mitigate human risk factors for successful clinician adoption of improvement strategies and technologies.
- Responsible for all activities required to ensure successful performance and participation in the Leapfrog survey, Value-based purchasing program, CHPSO, system level programs designed to achieve the Sutter system emphasis on High Reliability and commensurate quality dashboard targets as well as other relevant programs as assigned.
- Ensure regulatory compliance across the geography, including but limited to the Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), Institute for Medical Quality (IMQ) and the Joint Commission on Accreditation of Healthcare (TJC). Ensure special focus on applicable National Patient Safety Goals and Patient Safety indicators.
Measure performance improvement for quality, safety, regulatory and other pertinent initiatives
- Analyze, trend and report quantifiable improvements in cost and safe care related to PAMF/SMSC/MPMG projects and initiatives.
- In collaboration with the Data and Analytics team, monitor clinical and incident report data to identify and interpret changes in patient care outcomes, a safe environment for patient care and culture that is safe and just.
- Ensure appropriate actions and escalation pathways to PAMF/SMSC/MPMG operations and physician leadership, and local/system risk, quality and safety leadership are taken when errors have occurred and caused harm to members, patients, staff and/or the organization.
- Assist in the design/development of standardized reports relative to clinical care, service line analysis, harm reduction using comparative data and statistical analysis and utilizing appropriate methodologies and tools (e.g. lean tools, SPC charts, etc.)
Oversee Quality and Patient Safety Department operations and programs
- Ensure appropriate staffing as well as efficient and effective processes for each of the following programs: Infection Prevention and Control, Patient Safety, and all related programs and sub-processes.
- Manage the day to day operations and staff management such as hiring/terminating, providing annual evaluations, participation in GEMBA and regular feedback, manage budget within appropriate limits, manage employee expense reports and other department accounting, manage time cards, and perform other related duties as assigned/appropriate.
- Manage all relevant vendor relationships to support QPS department activities.
- Provide cross coverage to the QPS-Quality Manger during times of leave, absence and/or position vacancy.
Partner with PAMF/SMSC/MPMG, SPMF, SEBMF, Bay Area Operating Unit (BAOU) and system leadership to ensure synergistic working relationships, shared learnings, best practices, BAOU integration and department goal alignment.
- Promote a culture that perceives quality and safety as foundational across the enterprise.
- Participate in joint meetings within and outside of PAMF/SMSC/MPMG that promote system oneness where/when practical.
- Look to dovetail work whenever possible to reduce unnecessary system waste and to promote efficiencies and effective process improvement.
- Seek out alternate perspectives from multiple stakeholders to ensure robust improvement work and results.
Follows the commitment to excellence and treats patients, families, visitors and each other with courtesy, dignity, respect and professionalism REQUIRED: Bachelors; Minimum two (2) year of management experience in a medical office, clinic or hospital required.
- Ability to develop and implement departmental policies and procedures.
- Ability to travel to and from Santa Cruz half time and to travel to other PAMF locations at least one time per week and occasionally to the Sacramento Area.
- Ability to organize, plan, and implement various work projects.
- Ability to prioritize operations and direct staff to meet required goals
- Knowledge of current patient safety and quality improvement methodologies and ability to teach or implement quality improvement tools and techniques.
- Ability to facilitate teams or work groups to meet specified goals.
- Excellent communication and customer service skills (oral and written).
- Knowledge of medical terminology, anatomy and physiology.
- Ability to record and prepare committee minutes.
- Ability to utilize various relevant computer programs.
- Strong analytical and problem-solving skills
- Ability to work successfully with multidisciplinary groups of people to achieve desired outcomes,
- Ability to communicate both positive and negative outcomes