Quality Management Manager - Quality Improvement - Full Time - Days

Department: QUALITY IMPROVEMENT

Job Summary

In collaboration with Quality leadership, the Manager of Quality Management is responsible for delivering an integrated approach to performance improvement activities, clinical excellence, patient safety reporting, quality data collection, aggregation and analysis, identification of best practices, clinical outcomes, regulatory readiness and compliance. Serves as a resource while managing staff, activities and committees within MVHS related to clinical quality and improvement issues, accreditation and payor requirements, and other quality related initiatives.

Core Job Responsibilities

• Facilitate the hospital wide Performance Improvement (PI) program through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, Governing Body and internal stakeholders.

• Design, implement and facilitate programs or activities intended to improve performance in clinical quality, patient safety, and regulatory compliance throughout the hospital. Lead or participate actively on teams and committees related to Quality and Performance Improvement at MVHS.

• Obtain Quality Improvement information from Medical and Ancillary staff. Use data obtained from PI activities to define and act on opportunities to improve patient care processes. Regularly review clinical documentation, patient satisfaction records, and QIs to assess and identify trends. Recommend and implement process changes, policy changes, staff training or other appropriate mitigating factors in response to identified trends.

• Provide guidance to staff on effective evaluation and data collection techniques as well as aggregation and analysis tools for the promotion of quality care.

• Establish clinical quality assessment/improvement standards. Identify quality issues and conduct audits to further investigate issues. Audit departments or outside facilities as appropriate. Analyze audit results and submit reports on findings to leadership. Based on audit findings, recommend and implement preventive and/or corrective actions.

• Provide clarification on legal, policy or public relations issues and inter or intra-departmental changes or improvements.

• Prepare ad hoc and quarterly reports on QI activities.

• Maintain current knowledge in the regulations and requirements of accrediting agencies and payors through in-services, workshop attendance and independent study, etc.

• Proactively share knowledge of current Performance Improvement methodology and practices. Serve as a resource and role model to individuals and teams regarding quality, safety and compliance activities and best practices in Performance Improvement practices.

• Regularly assess the knowledge needs of clinical staff related to regulatory standards and deliver staff development programs to meet those requirements.

• Review and revise the Quality Management Plan and Quality Management policies and procedures. Establish and evaluate objectives for the Quality/Performance Improvement Service.

• Provide information to Quality Care Committee to contribute to their annual review of the Performance Improvement Program.

• In partnership with Human Resources and department leadership, make or approve recommendations on hires, transfers, terminations, promotions and similar actions. Complete performance appraisals, resolve grievances and handle other staff issues in a fair, timely and consistent manner, also in partnership with HR.

• Precept students on quality improvement topics.

• Perform other duties as required

Education/Experience Requirements

REQUIRED:

• Bachelor Degree in Nursing or health related field

• Five years’ clinical experience, with knowledge of pathophysiology, treatment of disease and patient management.

• Two years in a supervisory or management role.

• Demonstrated knowledge of Quality/Performance Improvement requirements and methodologies, including data collection/analysis.

• Previous experience or presently working in Quality Improvement field.

• Excellent verbal and written skills for communication with Administration, Medical Staff, Nursing Staff, and Ancillary Support Services

Licensure/Certification Requirements

REQUIRED:

• Registered Nurse licensed in the State of New York

Disclaimer

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor.

Job Details

Req Id 91452

Department QUALITY IMPROVEMENT

Shift Days

Shift Hours Worked 8.50

FTE 1.00

Work Schedule SALARIED MANAGEMENT

Employee Status A1 - Full-Time

Union Non-Union

Pay Range $97,000-$156,000 Annually