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 responsibilities include leading and implementing quality and safety strategies, overseeing quality, patient safety improvement, culture of safety (TogetherSafe), and infection prevention departments.

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 (CMO) or President in the absence of a CMO. The role requires incorporating MercyOne’s (Trinity Health) mission, vision, core values, and actions into behaviors, practices, and decisions.

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 support for quality, safety, and infection prevention staff.
• Lead or participate in quality and safety committees, including quality councils and board quality committees, to proactively address findings.
• Drive continuous improvement in CMS value-based programs, pay-for-performance initiatives, and TJC regulatory requirements.
• Achieve and sustain excellence in external rating organizations such as CMS, Leapfrog, Healthgrades, and Blue Distinction.
• Collaborate with accreditation, risk management, customer experience, and performance excellence leaders to support improvement initiatives.
• Develop quality excellence systems using LEAN and data-driven methodologies for continuous improvement.
• Provide oversight, support, or consultative services for quality improvement teams, including project design and data selection.
• Improve the culture of safety, including "Just Culture" and "TogetherSafe," and support cause analyses (e.g., root cause, HFMEA) and PSO initiatives.
• Oversee clinical data gathering and analytics to ensure accuracy of scorecards and dashboards for internal and external stakeholders.
• Promote shared leadership and decision-making within the organization.
• 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, and participate in the clinical contracting process.
• Contribute to evaluating medical staff performance, including focused and ongoing professional practice evaluations.
• Stay aware of and respond to issues such as cultural diversity, political and social influences, economic challenges, and ethical concerns in healthcare.
• Perform other duties consistent with the role as directed.

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 or manager-level role.
• National certification in quality/safety required or to be acquired within 2 years of hire.
• LEAN Six Sigma certification preferred.

Skills

• Member of a professional nursing organization.
• Demonstrated 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 or similar tools.