Manager of Quality and Safety

About the Role

The Manager of Quality and Safety is responsible for managing quality and safety programming at the local ministry level. This role involves collaborating with the ministry’s executive team, leadership, providers, and colleagues to cultivate high quality standards and achieve outcomes. Key areas of accountability include quality, patient safety improvement, culture of safety (TogetherSafe), and infection prevention.

The Manager reports directly to the MercyOne RHM Director of Quality and Safety of Hospitals, with an indirect reporting relationship to the local Chief Medical Officer (or President in the absence of a CMO). The role requires alignment with MercyOne (Trinity Health) mission, vision, core values, and promise.

Responsibilities

• Lead and manage quality, patient safety (including culture of safety initiatives), and infection prevention with high reliability principles, aiming for zero harm.
• Implement a quality performance improvement plan that meets CMS and The Joint Commission (TJC) regulations, in collaboration with executive teams, leadership, and committees.
• Collaborate with leadership, providers, and nursing staff to develop and implement quality and safety strategies for high-quality patient outcomes.
• Provide direct supervision, development, and competency oversight for quality, safety, and infection prevention staff.
• Lead or participate in quality and safety committees, including quality councils, board quality committees, and QICs.
• Identify and proactively address quality and safety focus areas to ensure high-quality, safe care.
• Drive continuous improvement in CMS value-based programs, commercial pay-for-performance programs, and TJC regulatory requirements.
• Achieve and sustain excellence in external rating organizations (e.g., CMS, Leapfrog, Healthgrades, Blue Distinction).
• Collaborate with accreditation, risk management, customer experience, and performance excellence leaders to support improvement initiatives.
• Develop data-driven quality excellence systems integrating LEAN and other methodologies.
• Provide oversight, support, or consultative services for quality improvement teams (e.g., project design, data selection, documentation tools).
• Improve the culture of safety, including "Just Culture" and "TogetherSafe," and support cause analyses (e.g., root cause, HFMEA, PSO initiatives).
• Oversee clinical data gathering/analytics to ensure accuracy of scorecards and dashboards for internal and external stakeholders.
• Promote shared leadership and decision-making.
• Maintain knowledge of applicable federal, state, and local laws, Trinity Health’s Organizational Integrity Program, and ethical standards.
• Support evidence-based practice, innovation, and research.
• Participate in the clinical contracting process in compliance with legal and regulatory requirements.
• Contribute to evaluating medical staff performance, including focused and ongoing professional practice evaluations.
• Stay aware of and respond to issues such as demographic changes, political/social influences, economic factors, and ethical healthcare challenges.
• Perform other duties as assigned.

Requirements

• Bachelor’s degree in nursing, health administration, or a related field (Master’s degree preferred).
• Iowa licensure as a Registered Nurse.
• Minimum of five (5) years of hospital experience in quality and/or safety, preferably in a progressive leadership role.
• National certification in quality/safety required (or to be acquired within 2 years of hire).
• LEAN Six Sigma certification preferred.

Skills

• Membership in a professional nursing organization.
• Expertise in performance improvement methodology and tools.
• Proficiency in computer applications, including Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, and reporting tools.
• Experience with event reporting systems, government reporting systems, and software like PowerChart/EPIC (preferred).