Quality Patient Safety Program Manager Licensed

As a Quality Patient Safety Professional, you will develop, implement, and monitor programs to enhance patient safety and drive continuous quality improvement.

Every day you will conduct risk assessments, analyze adverse events, identify root causes, and recommend evidence-based strategies. You will also collaborate with clinical teams and regulators, providing education and guidance on best practices.

To be successful, you will demonstrate a comprehensive understanding of patient safety principles, quality improvement, and healthcare regulations. Your analytical skills, attention to detail, and ability to influence change will be crucial for fostering a culture of safety and achieving exceptional patient outcomes.

• 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.
• *Reporting Structure may differ in Critical Access Hospitals

Required

• 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 audit, PI team member, etc.) and three (3) years clinical experience in an acute care setting.
• 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.
• Knowledge and expertise of quality management/performance improvement methods, tools, and techniques (e.g. PDSA, Tests of Change, Six Sigma, LEAN) and ability to create and support an environment that meets the quality goals of the organization.
• Current knowledge of data reporting and regulatory/accreditation requirements for acute and ambulatory care services and federal, state and local healthcare related laws and regulations and the ability to comply with these in healthcare practices and activities.
• Knowledge of effective self-management practices and ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Understanding of the necessity and value of accuracy and attention to detail.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Knowledge of the current situation or issue at hand; ability to take full personal responsibility or ownership for assignments, activities, decisions and results.
• Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions that resolve the problems in the best interest of the business.
• Ability to work well under pressure and respond to changing needs and complex environments
• Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization

Founded in 1887, Dignity Health - California Hospital Medical Center is a 318-bed, acute care, nonprofit hospital located in downtown Los Angeles, California. Serving over 100,000 patients annually, the hospital offers a full complement of services including a Level II Trauma Center, Level III NICU, heart care, women’s health, and a family birth center. In 2025, we opened our new patient tower, Grand Tower, featuring a dramatically expanded Emergency Department and Family Birth Center that will increase patient comfort and privacy. 

Additionally, California Hospital Medical Center has been recognized as an LGBTQ+ Healthcare Equality Leader by the Human Rights Campaign Foundation. It is a Joint Commission-certified Primary Stroke Center, and recently was awarded the AMA/ASA’s Get the Guidelines - Stroke Gold Plus Quality Achievement, recognizing the hospital’s commitment to providing the best stroke care. 

California Hospital Medical Center shares a legacy of humankindness with Dignity Health and CommonSpirit Health, one of the nation’s largest health care systems, dedicated to providing compassionate, high-quality, and affordable patient-centered care. 

One Community. One Mission. One California 

Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit our Total Rewards

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.