Manager of Quality - Patient Safety

Responsibilities

• Strategic: 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.
• Collaborates with the Chief Clinical & Quality Officer to advance AHMC in the High Reliability Organization (HRO) maturation journey.
• Evaluates aggregate data and outcomes from Performance Improvement collaboratives, ORYX/Core Measures, eCQMs, equity-focused stratification efforts, publicly reported data, and other comparative analysis.
• Advances SMC’s patient experience by mentoring, teaching, and coaching teams, providing feedback, support, and direction as needed.
• Works collaboratively with leadership and physician partners across the organization in identifying and managing 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.
• 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.
• Actively participates in patient leadership rounds to assess both the patient’s experience and culture of safety.
• Oversees the completion of required action plans and ensures ongoing assessment and compliance.

Qualifications/Job Requirements

• Education: Bachelor's degree in a healthcare-related field (e.g., nursing, public health, healthcare administration). Advanced degrees (e.g., Master's) is preferred.
• 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.
• Regulatory Knowledge: Comprehensive knowledge of regulatory requirements for areas of responsibility (e.g. TJC, CDPH, CMS, Conditions of Participation).
• Skills: Strong communication, interpersonal, and presentation skills.
• Experience: Experience in managing issues related to area of responsibility.
• Technical Skills: Computer/Information system experience preferred.