Hospital Quality Nurse Manager - Collaborative Environment

The Quality Manager plans, directs, and evaluates patient care; facilitates quality improvement efforts and regulatory requirements among the Medical Staff and Hospital departments through data collection, aggregation, analysis and reporting.

The Quality Manager is responsible for evaluating, recognizing, coordinating, developing, and implementing, overall Quality Improvement program, to identify trends, prioritize and recommend improvements, and ensure compliance of state and federal regulations. Investigate incident reports, quality care concerns, patient complaints, and patient care issues. Utilizes a variety of quality measuring tools and techniques to monitor processes and outcomes. Analyze and provide data to the appropriate staff to assist in identifying opportunities for improvement. Acts as a resource for the medical and hospital staff regarding the continuous quality improvement process.

1. Responsible for gathering and reporting in-patient and out-patient quality data to various Quality improvement organizations including Telligen, eQHealth Solutions, IDPH, Healthcare Facilities Accreditation Program (HFAP), CMS and others.

2. Reports quarterly and annual hospital quality data as required by state and federal regulations.

3. Ensures compliance with state and federal regulations pertaining to patient safety and quality improvement.

4. Serve as a quality liaison and educational resource to clinical team leaders and Medical Staff.

5. Provides feedback to Physicians and other healthcare team members on their performance on the quality measures.

6. Perform Clinical reviews utilizing quality tools-RCA, FEMA, PDSA.

7. Identifies adverse incidents and Quality of Care concerns. Trends and recommends improvements.

8. Develop and implement QI projects and QI measures to improve compliance with the quality measures.

9. Facilitates processes for establishing and implementing policies/procedures to address patient safety and quality of care.

IO. Provides reports to the various Medical Staff Committees as well as the month.