Quality Manager Jobs

The Manager of Quality and Performance Excellence is responsible for management and measurement of standards, programs and practices addressing quality, patient safety and integration of patient care for Sheridan Memorial Hospital in accordance with the overall strategic objectives and applicable regulatory requirements. The Manager of Quality and Performance Excellence directs the quality and performance improvement functions. The incumbent provides leadership necessary to achieve national best practice performance levels in quality improvement while implementing evidence based practices, ensures that the quality of healthcare services rendered meets or exceeds professionally recognized community standards, interfaces with a diverse range of clinical and administrative professionals, resolves sometimes-complex policy and service issues and directs data analytic and reporting activities that are prescribed by customers and regulators, and ensures compliance with state, federal and accreditation requirements. This position is responsible for meeting performance expectations in the areas of quality care, patient safety, service excellence, resource utilization, EHR integration, accreditation, infection control and employee health.

Areas of Direct Reporting include: Accreditation and Regulatory Compliance, Infection Prevention, Patient Safety,/ Social Work / Utilization Review and Employee Health / Worker’s Compensation.

ESSENTIAL DUTIES/RESPONSIBILITIES

• Reviews the validation and verification of the Electronic Medical Record
• Institutes programs that improve quality and patient safety, and reports results to SMH leadership as well as applicable state and federal agencies.
• Acts as a champion and a change agent to shift the focus to patient safety and prevention of patient injuries by improving and changing processes, identifying gaps in complex systems and decreasing error-prone incidents.
• Expertise in application of CMS Conditions of Participation and other regulations and standards for the Joint Commission and consistently updated the department accordingly.
• Cultivates and maintains professional relationships with primary customers including physicians, patients and external entities to foster opportunities for improvement in quality metrics, enhanced customer service and to positively impact core measures.
• Provides guidance and facilitates integration and communication of proactive safety plans to reduce risk within the organization.
• Works with department managers to ensure all departments are working in concert with each other to achieve quality outcomes in safety, satisfaction, service and process improvement.
• Plans, directs and evaluates the work of staff; complies with human resource management policies and procedures; ensures adequate staffing levels, allocates resources; ensures that employees are qualified, trained and meet customer service standards; makes employment decisions, utilize best practices for performance management to include rounding, completes performance appraisals; coaches and develops staff and addresses performance concerns in conjunction with the Quality Director.
• Develops and implements systems, policies, and procedures for the identification, collection, and analysis of performance measurement data.
• Ensures compliance with legal and regulatory requirements, monitors the effectiveness of current practices and procedures in producing desired results. Keeps abreast of regulatory requirements, professional standards and competitive industry practices, as well as organizational initiatives with potential to impact current strategies.
• Administers annual operating budget, identifies resources needed to accomplish performance objectives; exercises cost control to stay within budget; identifies variances and develops action plan to address; keeps leadership appraised of budgetary impact issues in conjunction with the Quality Director.
• Provides leadership and assumes accountability through development, implementation and monitoring of quality improvement programs, systems and initiatives impacting the entire organization to facilitate performance and process improvements in keeping with patient, safety, strategic objectives and regulatory requirements. Oversight and monitoring of Patient Satisfaction data; works with Patient Satisfaction vendor to consult and provide best practices and strategies for SMH.
• Works closely with the Quality Director, hospital and Medical Staff. , and communicates to the Quality Committee, Executive Team, Medical Executive Committee and Board of Trustees.
• Provides strategic and operational leadership for the integration and evaluation of the electronic medical record and other technology from the nursing practice perspective.
• Reviews Medical Management data for trends and opportunities for improvement. Reviews current processes regularly to ensure maximum efficiency and effectiveness including but are not limited to: Length of stay, re-admissions, denials, and RAC.

Leadership and Human Resource Management

Demonstrates consistent leadership performance and behavior by actively being engaged in making SMH/BHHN a five-star provider of quality care by being a positive force within the organization and actively promoting teamwork and harmony. Delegates effectively and supervises follow-through. Persuasive, fair, impartial, sets high standards, and ensures clear focus and direction. Achieves desired results with support, confidence and integrity. Regularly recognizes achievements of others. Leads others to success, supporting individual and team accomplishments.

Supervisor duties and responsibilities include:

• Provides development opportunities for staff to broaden and enhance skills and abilities.
• Ensures high level of performance standards and achievement to meet organization needs and business goals.
• Writes and conducts annual performance appraisals and ensures regular ongoing feedback, coaching, and communication with staff.
• Administers organization policies and procedures.
• Promotes an environment that fosters teamwork and commitment to satisfy customer requirements.
• Ensures compliance with safety policies and good housekeeping.
• Manages initial training of new employees and ongoing training as required.

POSITION QUALIFICATIONS

Education / Experience / License and Certifications

• Master’s degree preferred.
• Minimum of 3 years supervisory experience, preferred.
• Comprehensive (wide base) knowledge of patient care and hospital systems.
• Bachelor's degree in Nursing, Business Administration or health services administration required.
• Strong analytical and problem solving skills.
• Experience in a decision making, change management, performance improvement, quality, patient safety and informatics.
• Minimum of 3 years of related experience, preferred.
• Ability to multitask in a fast paced environment.
• Maintains clinical license and certifications, if applicable. ie: RN, PA/NP, Pharmacist
• Certified Professional in Healthcare Quality (CPHQ), preferred.

Additional Skills

• Adheres to organizational and department specific safety standards and guidelines.
• Maintains confidentiality and protects sensitive data at all times.
• Works collaboratively and supports efforts of team members.
• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, visitors, staff and the broader health care community.

In accordance with Sheridan Memorial Hospital’s (SMH) duty to maintain a safe work environment for staff, patients and visitors, and to ensure the facility remains in compliance with the Center for Medicare and Medicaid Services (CMS) Conditions of Participation, COVID-19 vaccinations or an approved medical or religious exemption is required in accordance with established CMS requirements.

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products.

Pre-employment drug and alcohol screening is required.

Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer and gives consideration for employment to qualified applicants without regard to race, color, religion, age, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights as an applicant under the law, please click here.