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Patient Safety/Peer Review - Program Manager (RN)

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Requisition # HRC0712450

The Patient Safety/Peer Review - Program Manager (RN) provides direction for day-to-day operations and administrative activities for the Patient Safety and Peer Review Program. The Program Manager contributes to the strategic planning, design, development and implementation of program objectives, procedures, processes, and standards.

The Program Manager develops and implements the patient safety plan, processes and facilitates the education and communication of patient safety across the hospital.  Facilitates peer review activity in collaboration with the medical staff services department. Acts as a resource to executive leadership, medical staff, nursing, and other hospital and health system personnel with regard to patient safety and peer review issues and activities. The Program Manager is responsible for conducting continuous hospital-wide safety assessments, implementing, and then evaluating safety practices.

 

  • Management and formal initiation of CS-MDRH Patient Safety Program - Provides management and oversight of patient safety initiatives and projects. Coordinates patient safety efforts with various departments/stakeholders.  Provides consultation to medical staff, senior, and service line management to incorporate concepts of safety into daily work. 
  • Establishes priorities and organizing initiatives to maintain meaningful peer review activities in accordance with the Medical Staff Bylaws and Rules and Regulations.
  • Peer Review Program - Collaborates with the medical staff services department, peer review committee chair, and the CMO to manage the peer review process for CS-MDRH. Oversight includes case screening, case review, case prep, data tracking and trending, creating reports and presentations for various committees, as required and any additional tasks related to peer review program.
  • Culture of Safety Survey - In collaboration with Organizational Development, plan, coordinate and assist with implementation of the biennial Culture of Safety Survey, working with clinical and operational leaders to identify opportunities and develop action plans.
  • Legal and Regulatory Compliance - Establishes and maintains systems to ensure organization compliance with legal and regulatory standards, hospital policies and procedures.   Serves as a resource person for addressing TJC, CMS, and Title 22 standards and requirements relating to patient safety
  • Facilitates immediate risk mitigation response to Significant Adverse Events and facilitates Root Cause Analysis (RCA) process. 
  • Continuous Quality Improvement - Develops, implements, monitors, and champions performance improvement processes and policies relating to key patient safety issues.  Adopts principles of Continuous Quality Improvement in all areas of responsibility.
  • Event Review Screening - Manages the screening process for peer review to include appropriate capture of cases, clinical screening according to criteria or knowledge/expertise, use of appropriate technology, review and identification of patterns or trends.
  • Lead with various stakeholders a biennial risk assessment on high-risk processes (FMEA)


Qualifications

Education:

  • Bachelor’s Degree, Nursing (required)
  • Master’s Degree, MPH, MHA, MBA, or MSN (preferred)

Experience:

  • 5 years of Acute Care Experience (required)
  • 2 years of Experience in Project Management and or Leading Quality Improvement Programs/Projects (preferred)               

Licensure:

  • Current California Registered Nurse License (required)

Cedars-Sinai Marina del Rey Hospital is an EEO employer. Cedars-Sinai Marina del Rey Hospital does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.

Cedars-Sinai Marina del Rey Hospital will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

At Cedars-Sinai Marina del Rey Hospital, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu) and COVID-19. For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a conditiosn of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai Marina del Rey Hospital reserves the right to make modifications to its required list of vaccines as required by law and/or policy.

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  • Administrative, Marina del Rey, California, United StatesRemove