Manager Quality Improvement Organizational Excellence

Provides technical direction and administration of assigned department(s) ensuring services are provided efficiently and effectively. Regularly reviews and revises, as necessary, relevant standards and ensures services performed comply with all hospital, system, and regulatory agency standards. Coordinates the quality improvement and organizational excellence plan with other nursing and medical functions and serves as technical resource for departmental personnel. As an expert in the assigned areas, is a resource person to both staff and physicians. Oversees, guides, and mentors the entire team and conducts staff evaluations.

Essential Functions and Responsibilities:

1. Plans and administers directly, and through subordinate supervisory personnel, the effective management and delivery of services in accordance with all hospital, system, patient safety, and regulatory agency standards.
2. Assists with ensuring quality, financial, and customer service objectives are met.
3. Assists with developing and administering capital and operating budgets in order to meet agreed-upon departmental goals and objectives. Implements appropriate methods to monitor adherence to budgets and resolve variances.

4. Gathers and maintains accurate quality data and records of activities:

a. Ensures the quality and integrity of the data through development and/or implementation of quality control and audit procedures

b. Applies generic and specific clinical indicator screens or criteria to identify potential quality and risk management concerns

1. Assists with recommendations for new supplies and minor equipment purchases.
2. Fosters smoothly running quality improvement services and processes through timely and effective resolution of disruptions.
3. Develop and maintain reporting mechanisms and project plans that allow for the tracking and trending of accrediting body performance measures, quality initiatives and the monitoring of progress related to accreditation
4. Ensures the attainment of objectives through the selection, development, training, and evaluation of quality improvement services staff.
5. Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
6. Performs other related duties as required and directed.

Qualifications:

Required

• Associate’s degree in nursing, healthcare administration, business administration, or related field from an accredited educational institution

• Knowledge of current and emerging regulatory, accreditation requirements/standards (i.e., CMS, Joint Commission, HFAP, DNV) related to hospital and other healthcare organizations

• Three years of progressively responsible experience in a health care environment, including experience in management of clinical services and process improvement/quality/safety management areas

• Certification in Quality Improvement/ Patient Safety (i.e., CPHQ, ASQ, CQIA, Team STEPPS Master Trainer, Project Management) or must be obtained within two years of employment

Preferred:

• Bachelor’s degree in nursing, healthcare administration, business administration, or related field from an accredited educational institution

• LEAN/Six Sigma Certification