Mgr, Quality

Overview

Saint Francis Hospital - Bartlett Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients. At Saint Francis Hospital - Bartlett, We Understand That Our Greatest Asset Is Our Dedicated Team Of Professionals. That’s Why We Offer More Than a Job – We Provide a Comprehensive Benefit Package That Prioritizes Your Health, Professional Development, And Work-life Balance.

Description

Job Summary

The Manager, Quality is responsible for leading quality improvement initiatives, performance improvement activities, patient safety programs, and regulatory readiness efforts under the direction of the Director of Quality. This role collaborates with physicians, nursing leadership, operational leaders, and frontline staff to improve clinical outcomes, enhance patient safety, ensure regulatory compliance, and support a culture of continuous improvement.

Responsibilities

• Facilitates quality improvement projects using evidence-based methodologies and performance improvement tools.
• Makes sure that organizational quality metrics are monitored and identifies opportunities for improvement.
• Facilitates the development, implementation, and evaluation of corrective action plans.
• Supports Quality Assessment and Performance Improvement (QAPI) activities.
• Aids departments in achieving quality and patient safety goals.
• Analyzes clinical performance data and identifies trends, risks, and improvement opportunities.
• Develops and maintains quality dashboards and scorecards.
• Collaborates with operational leaders to improve outcomes related to mortality, readmissions, hospital-acquired conditions, and patient experience.
• Ensures timely and accurate reporting of quality measures.
• Promotes a culture of safety and high reliability.
• Supports ongoing readiness for CMS, state, and accreditation surveys.
• Makes sure compliance with regulatory and accreditation standards is maintained.
• Facilitates survey preparation, mock surveys, and corrective action plan development.
• Provides education regarding regulatory and accreditation requirements.
• Presents quality and patient safety data to committees and leadership teams.
• Facilitates interdisciplinary teams focused on quality improvement initiatives.
• Supports medical staff quality and peer review activities.

Qualifications

• Education Required: Bachelor’s degree or higher in a patient care-related field.
• Preferred: Bachelor's or master's degree in nursing.
• Experience Required: 3 years of combined experience in hospital clinical practice and Quality Management. 1 year of experience in hospital Quality Management.
• Experience with regulatory and accreditation standards.
• Extensive experience in concepts associated with RCA’s and developing, implementing, and monitoring robust quality and process improvement activities.
• Preferred: 1 year as a hospital Quality Manager.
• Certification(s) Preferred: Registered Nurse. CPHQ, CPPS, HACP-CMS.