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.Principal Duties and Accountabilities:-Assists in the design, planning, implementation and coordination of Quality Mgmt., 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, and root cause analyses and medical staff improvement (e.g. 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.

• Worked collaboratively with Executive Hospital leadership, medical/clinical staff, and ancillary departments to improve organizational privacy compliance.• Working knowledge of STARK Law, Anti-kick back law, CMS, TJC, OCR, HITECH & HIPAA• Responsible for investigating, collaborating, and reporting privacy breaches to local and federal regulatory bodies for three local Dignity Health Facilities.• Effectively managed and met deadlines reporting requirements in an ever changing environment.• Responsible for risk mitigation related to reportable privacy events.• Provided education to staff and departments related to privacy compliance.• Conducted HIPAA Audits for three local Dignity Health Facilities.• Responsible for entering and managing privacy and compliance events entered into Compliance360.• Analyzed and prepared reports for hospital committees and Hospital Leadership.• Developed various types of action plans for privacy compliance improvement.• Performed audits from which data was used to track and trend privacy/compliance measures. • Evaluated policies/processes/procedures and provided recommendations for improvement.

• Managed the BMH Event Reporting System (ERS). • Responsible for event integrity and assuring complete and accurate information was entered into the system.• Collaborated with responsible party for completing event reports and for submission of additional documents. • Responsible for reporting Hospital Acquired Pressure Ulcers and assisting in the investigation of those events. • Responsible for collaboration with local CDPH for follow up on reported events. • Worked Collaboratively with Director of Professional Nursing Practice for HAPU and Fall data via ERS system and applicable Root Cause Analysis (RCA). • Assisted Director of Risk Management with BMH events pending or in active litigation. • Assisted attorneys’ offices representing BMH for the litigation cases. • Responsible for Root Cause Analysis for reportable events, sentinel events, and events deemed necessary by hospital leadership. • Member of RCA team reviewing events for possible patient safety concerns and potential cases for litigation against BMH

• Created and implemented audits tools to collect clinical and environmental data throughout the hospital and outlying buildings. • Conducted in depth chart reviews for appropriate documentation related to rules and regulations.• Worked collaboratively with staff, managers, directors, and executive leadership based on the data findings for root cause analysis and organizational improvement. • Performed real time education with staff regarding findings and served as a resource to staff for regulatory, best practice, and policy/procedure related questions/concerns.• Working knowledge of CMS & TJC.

• Established business contact and professional relationships with local health care providers.• Marketed to local area Physicians and health care providers related to outpatient services and programs.• Responsible for media releases and appointments for the CEO.• Increased patient referrals by 5% to 20% a month on average.• Motivated staff by creating an environment conducive to communication and collaboration.• Organized community Wellness events through collaboration and procurement.• Proficient with Microsoft Word, Excel, and PowerPoint, Cerner, MediTech, and Verge Solutions.