Mgr, Quality

DESCRIPTION

The Manager, Quality is responsible for leading quality improvement initiatives, performance improvement activities, patient safety programs, and regulatory readiness efforts under the direction of the Director of Quality. This role collaborates with physicians, nursing leadership, operational leaders, and frontline staff to improve clinical outcomes, enhance patient safety, ensure regulatory compliance, and support a culture of continuous improvement.

RESPONSIBILITIES

Facilitates quality improvement projects using evidence-based methodologies and performance improvement tools. Monitors organizational quality metrics and identify opportunities for improvement. Facilitates development, implementation, and evaluation of corrective action plans. Supports Quality Assessment and Performance Improvement (QAPI) activities. Assists departments in achieving quality and patient safety goals. Analyzes clinical performance data and identify trends, risks, and improvement opportunities. Develops and maintains quality dashboards and scorecards. Collaborates with operational leaders to improve outcomes related to mortality, readmissions, hospital-acquired conditions, and patient experience. Ensures timely and accurate reporting of quality measures. Promotes a culture of safety and high reliability. Supports ongoing readiness for CMS, state, and accreditation surveys. Monitors compliance with regulatory and accreditation standards. Facilitates survey preparation, mock surveys, and corrective action plan development. Provides education regarding regulatory and accreditation requirements. Presents quality and patient safety data to committees and leadership teams. Facilitates interdisciplinary teams focused on quality improvement initiatives. Supports medical staff quality and peer review activities.

QUALIFICATIONS

Education:

Required: Bachelor�s degree or higher in a patient care-related field. 
Preferred: Bachelor's or master's degree in nursing.  

Experience:

Required:  3 years of combined experience in hospital clinical practice and Quality Management. 1 year of experience in hospital Quality Management. Experience with regulatory and accreditation standards. Extensive experience in concepts associated with RCA�s and developing, implementing, and monitoring robust quality and process improvement activities.

Preferred: 1 year as a hospital Quality Manager

Certification(s): 

Preferred:  Registered Nurse. CPHQ, CPPS, HACP-CMS 

Physical Demands:

Not Applicable

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