Reports to the Executive Director of Quality. Responsible for organizing, planning and directing the efficient operation of the Quality Management department. Directs the Hospital's quality improvement processes and programs. Develops, recommends and administers departmental policies and procedures in accordance with established Hospital guidelines. Supervises assigned Quality Management associates including other Beacon organizations. The Quality Manager participates in the planning, implementation and evaluation of the quality, patient safety and operational performance improvement program. The manager serves as a project manager for entity quality and safety projects, while also serving as an advisor and local change agent for hospital and associated business entities and other areas as assigned. The Quality Manager supports teams with the most current PI methods and tools, including project management support. This work includes, though is not limited to, facilitation of PI projects and workshops, management and surveillance of data for PI opportunities, messaging trends in the data to departments and staff, education of staff in the latest PI methods, and responding to serious patient safety events. This position is accountable for facilitating improvement in the areas of clinical quality and patient safety, patient satisfaction and clinical operations and promotes organization high reliability.
- MISSION: We deliver outstanding care, inspire health, and connect with heart.
- VALUES: Trust. Respect. Integrity. Compassion.
- SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Establishes Quality Management department direction in accordance with Hospital guidelines and established goals and objectives by:
- Determining short- and long-term objectives consistent with the goals of the Hospital.
- Recommending policies and standards for the department.
- Formulating personnel, expense and capital equipment budgets for the department.
- Providing departmental leadership and guidance.
Supervises Quality Management staff by:
- Conducting interviews and hiring qualified candidates for open budgeted positions.
- Evaluating performance of those supervised and recommending salary increases.
- Counseling employees as necessary and interpreting Hospital and departmental policies and procedures.
Coordinates Quality Management department services with other departments and serves as a liaison for the department by:
- Advising Executive Director of Quality regarding department status and needs.
- Participating in department directors' meetings and serving on various committees as assigned.
- Establishing and maintaining effective communications and working relationships with the Medical Staff, Vice President of Medical Affairs and other departments.
- Participating in professional and community activities.
- Facilitating Participating in meetings for the Medical Staff Quality Committee.
- Attending Medical Staff meetings to facilitate presentations on quality and monitoring results as needed.
- Supporting Quality Management liaison to Hospital system committees requiring quality outcome data information.
- Coordinating or initiating correspondence or quality plans to Medicare PRO and other outside agencies.
Enhances Quality Outcomes by:
- Leads or participates in improvement work in patient satisfaction, patient safety, clinical quality and operations.
- Utilize and share with teams the various high reliability and PI tools, methods and approaches.
- Facilitates projects and workshops to support teams, maintaining a collaborative partnership with healthcare system leaders and associates.
- Serve as a change-agent in efforts for quality/safety improvement.
- Ensuring compliance of external and internal regulatory requirements related to accreditation and licensure.
- Supervises and directs the clinical data analyst staff to identify trends in data to develop action plans to improve clinical outcomes.
- Understand, disseminate and communicate trends in quality and safety data.
- Explain the meaning of process and outcome data and how it reflects success in performance improvement. Identify, implement and monitor action plans to address opportunities for improvement.
- Promotes a culture of safety; assists with the Patient Safety Culture Survey and action plan.
- Helps develop project plans and facilitates improvement in our risk reduction initiatives.
- Oversees the training, monitoring of event submissions, event trends and action plans as it relates to quality patient safety. Responds to serious safety events and communicates to practices and leadership as appropriate.
- Responsible for the growth in use of high reliability strategies.
- Responsible for the creation, review, revision and communication of clinical/safety related policies.
- Other duties as assigned to support the unit, department, entity, and health system organization.
Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
- Acting as a clinical resource to other department members.
- Completing other job-related assignments and special projects as directed.
Leadership Competencies
- Drives Results - Consistently achieving results, even under tough circumstances.
- Customer Focus - Building strong customer relationships and delivering customer-centric solutions.
- Instills Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.
- Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
- Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
Associate complies with the following organizational requirements:
- Attends and participates in department meetings and is accountable for all information shared.
- Completes mandatory education, annual competencies and department specific education within established timeframes.
- Completes annual employee health requirements within established timeframes.
- Maintains license/certification, registration in good standing throughout fiscal year.
- Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department.
- Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
- Adheres to regulatory agency requirements, survey process and compliance.
- Complies with established organization and department policies.
- Available to work overtime in addition to working additional or other shifts and schedules when required.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
- Leverage innovation everywhere.
- Cultivate human talent.
- Embrace performance improvement.
- Build greatness through accountability.
- Use information to improve and advance.
- Communicate clearly and continuously.
Education and Experience
- Bachelor's degree or clinical degree required; master's degree preferred. Nursing experience is required.
- BSN required and 5+ years knowledge and experience in quality improvement modes, such as Lean/Six Sigma, the IHI Model for Improvement, or other comparable performance improvement strategies. Knowledge of Joint Commission, CMS and Indiana Department of Health standards/regulations is required. Knowledge of national standards and outcomes for quality, safety and healthcare Anthem Measures and Value Based Purchasing, AHRQ, Leapfrog, Experience with Root Cause Analysis and Healthcare Failure Mode and Effects Analysis.
Knowledge & Skills
- Demonstrates administrative and supervisory skills necessary to direct a number of organization programs and supervise professional and paraprofessional staff.
- Demonstrates analytical skills necessary to develop programs, evaluate projects and approve or recommend changes in policies and procedures and staffing levels that affect the Quality Management department. Demonstrate accurate, thorough data collection and analysis and have knowledge and experience of Microsoft Office, SharePoint, and project management tracking tools.
- Demonstrates interpersonal skills necessary to interact effectively with a variety of contacts within and outside the Hospital (i.e., medical staff, hospital department directors, external regulating agencies, etc.).
- Demonstrates well-developed communication skills (both verbal and written).
- Demonstrates ability to make effective presentations before groups of various sizes.
- Demonstrates initiative, judgment, creativity and leadership abilities. Change management skills and the ability to network and influence. Have consultative, team building, and group facilitative skills, as well as strong project management skills.
Working Conditions
- Works in an office environment.
Physical Demands
- Requires the physical ability and stamina to perform the essential functions of the position.
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