Overview

The Manager of Quality and Patient Safety is responsible for ensuring and maintaining quality standards in all aspects of patient care and hospital operations. This includes overseeing quality improvement initiatives, monitoring performance data, and implementing strategies to enhance patient safety and clinical outcomes.

The Manager of Quality and Patient Safety works collaboratively with the Chief Clinical & Quality Officer to oversee all clinical quality and performance improvement initiatives to support a culture of safety at AHMC Seton Medical Center. This position provides leadership for quality data and performance improvement in the development, implementation, measurement, and monitoring of strategic initiatives that ensure that clinical quality outcomes are being met. The focus of this position is on achieving excellent patient care outcomes, decreasing patient harm and adverse events, and identifying performance improvement opportunities to optimize patient care. The manager will oversee the development, initiation, and sustainment of performance improvement initiatives in quality and patient safety, as well as evidence-based care guidelines and policies to ensure that SMC achieves optimal healthcare outcomes for the patients we serve.

Responsibilities

RESPONSIBILITIESStrategic:

● The Manager of Quality and Patient Safety will continuously assess, review, evaluate, and implement programs to expand what the organization is outlined by the Strategic Plan, as well as other hospital quality metrics.● Supports the strategic plan and the goals and direction of the performance improvement plan.● In collaboration with theChief Clinical & Quality Officer, the Manager of Quality and Patient Safety will advance AHMC in the High Reliability Organization (HRO) maturation journey.● The Manager of Quality of Patient Safety will evaluate aggregate data and outcomes from Performance Improvement collaboratives, ORYX/Core Measures, eCQMs, equity-focused stratification efforts, publicly reported data, and other comparative analysis.● In collaboration with the Chief Clinical & Quality Officer, the Manager of Quality and Patient Safety will advance SMC’s patient experience.

Operations:● Mentoring, teaching, and coaching teams, providing feedback, support, and direction as needed; viewed as a PI resource for the entity.● Provides departments and service lines with the most current PI methods, assisting in seeking areas for improvement and the facilitation of projects while working with varying levels of professional, clinical, and ancillary staff.● Works collaboratively with leadership and physician partners across the organization in the following roles: identification and management of key performance indicators, audit workflows, action planning, and investigation.● Provides statistical analysis of key performance metrics and assists department leaders in the preparation and analysis of data.● Able to competently evaluate and facilitate improvement activities by providing useful feedback to ensure safe, effective, and compliant patient services. Able to communicate effectively both verbally and in writing.● Performs quality chart reviews and monitors compliance for publicly reported data and key quality performance metrics.● Manages assigned projects within the facility in an organized, professional, and timely manner, including developing work plans, ongoing evaluation of progress, and reporting the results and reasons for variances to appropriate leadership.● Participates actively in Medical Staff committees, including departmental meetings.● Provides teams with the most current PI methods and tools, including project management support.● Actively participates in patient leadership rounds to assess both the patient’s experience and culture of safety.● Develops and implements policies and procedures in compliance with regulatory requirements● Ensures cost-effective daily operations and allocation of resources.● Effectively manages members of the quality department team.

Regulatory:● Actively participates in Continuous Regulatory/Survey Readiness.● Ensures compliance with healthcare regulations and standards● Participates in tracer activity, clinical and/or environmental rounds when appropriate to maintain a state of continuous service readiness for regulatory surveys.● Oversees the completion of required action plans and ensures ongoing assessment and compliance.

Qualifications

QUALIFICATIONS/JOB REQUIREMENTSEDUCATION● Bachelor's degree in a healthcare-related field (e.g., nursing, public health, healthcare administration).● Advanced degrees (e.g., Master's) is preferred.● Experience in quality management, performance improvements● Certification in related field preferred but not required

EXPERIENCE● Minimum of 2 years of experience in the areas of quality management, performance improvement, data analytics, patient safety required.● 1 year of experience as Quality Data Analyst● Comprehensive knowledge of regulatory requirements for areas of responsibility (e.g. TJC, CDPH, CMS, Conditions of Participation)● Strong communication, interpersonal, and presentation skills● Experience in managing issues related to area of responsibility● Computer/ Information system experience preferred● Ability to work collaboratively with physicians