Job Description

**Responsibilities** The Licensed Quality/Patient Safety Program Manager plays a key role in supporting and coordinating quality management (QM), patient safety (PS), and regulatory performance improvement (PI) activities within the hospital and medical staff. This position serves as a resource for employees, management, nursing directors, senior leadership, physicians, and teams on QM initiatives. The role involves handling patient-sensitive and confidential information while driving continuous improvement in clinical quality, patient safety, and regulatory compliance. **Key Responsibilities:** + Assist in the design, planning, and coordination of QM, PS, and PI activities across hospital departments, committees, and service lines. + Facilitate performance improvement teams focused on clinical quality improvement, patient safety, risk reduction, and medical staff improvement activities. + Ensure compliance with CMS HIQRP/HOQRP, The Joint Commission (TJC), Leapfrog, and other regulatory standards through effective data collection and reporting. + Develop and implement data collection tools and processes, ensuring accuracy and validation of data. + Present data findings, facilitate meetings, and support the creation and implementation of action plans. + Maintain up-to-date knowledge of accreditation and licensing requirements, supporting regulatory readiness and survey preparation activities, including mock survey tracers. This role requires strong organizational, analytical, and leadership skills to effectively manage performance improvement initiatives and ensure compliance with regulatory standards. **Qualifications** + Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff (Current state license in a clinical field in state of practice.) + Three (3) years of clinical experience in an acute care setting + One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.) + 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** Founded in 1910, Dignity Health - Community Hospital of San Bernardino is a 347-bed, acute care, nonprofit, community hospital located in San Bernardino, California. Known for its programs in maternity care and pediatrics, behavioral health and long-term subacute care for adults and children, the hospital also includes inpatient and outpatient surgery. The hospital shares a legacy of humankindness with Dignity Health, one of the nation's five largest health care systems. Visit here ( for more information. 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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