Job Description

**Responsibilities** Position Summary: 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. Assists in the design, planning, implementation and coordination of QM, PS and PI 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, and root cause analyses and medical staff improvement (e.g. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review. 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. **Qualifications** Education and Experience: + Bachelor's degree or five (5) years of related job or industry experience in lieu of degree. + One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audits, PI team member, etc.) and three (3) years clinical experience in an acute care setting. Licensure: + 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. **Overview** Bakersfield Memorial Hospital includes 385 general acute beds, 48 licensed critical care beds, 13 state-of-the-art surgical suites, and a full-service Emergency Department with an Accredited Chest Pain Center and Nationally Certified Stroke Center. In addition, we offer a beautiful Family Care and Birthing Center, the Lauren Small Children's Center including the area's only Pediatric Intensive Care Unit, Family Care Center, a Level II NICU, the Sarvanand Heart, and Brain Center with Kern County's first Bi-Plane Interventional Suite, the Center for Wound Care and Hyperbarics, and many more services. Memorial Hospital is a Children's Miracle Network Hospital and is home to the Bakersfield Ronald McDonald House. Memorial Hospital is a member of Dignity Health and is a trusted community partner, serving residents of Bakersfield and Kern County with quality, compassionate care since 1956. Click here ( to learn more about Bakersfield Memorial Hospital. One Community. One Mission. One California ( **Pay Range** $49.20 - $71.34 /hour We are an equal opportunity/affirmative action employer.

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