Mgr Quality Management (BHS)

About the role

Reports to the Executive Director of Quality. Responsible for organizing, planning and directing the efficient operation of the Quality Management department. Directs the Hospital's quality improvement processes and programs. Develops, recommends and administers departmental policies and procedures in accordance with established Hospital guidelines. Supervises assigned Quality Management associates including other Beacon organizations.

Responsibilities

• Participates in the planning, implementation and evaluation of the quality, patient safety and operational performance improvement program.
• Serves as a project manager for entity quality and safety projects, while also serving as an advisor and local change agent for hospital and associated business entities and other areas as assigned.
• Supports teams with the most current PI methods and tools, including project management support.
• Facilitates PI projects and workshops, manages and surveils data for PI opportunities, messages trends in the data to departments and staff, educates staff in the latest PI methods, and responds to serious patient safety events.
• Facilitates Participating in meetings for the Medical Staff Quality Committee.
• Attends Medical Staff meetings to facilitate presentations on quality and monitoring results as needed.
• Serves as a liaison for the department by advising Executive Director of Quality regarding department status and needs, participating in department directors' meetings and serving on various committees as assigned.
• Establishes and maintains effective communications and working relationships with the Medical Staff, Vice President of Medical Affairs and other departments.
• Participates in professional and community activities.
• Facilitates Quality Management liaison to Hospital system committees requiring quality outcome data information.
• Coordinates or initiates correspondence or quality plans to Medicare PRO and other outside agencies.
• Enhances Quality Outcomes By Leads or participates in improvement work in patient satisfaction, patient safety, clinical quality and operations.
• Utilizes and shares with teams the various high reliability and PI tools, methods and approaches.
• Facilitates projects and workshops to support teams, maintaining a collaborative partnership with healthcare system leaders and associates.
• Serve as a change-agent in efforts for quality/safety improvement.
• Ensures compliance of external and internal regulatory requirements related to accreditation and licensure.
• Supervises and directs the clinical data analyst staff to identify trends in data to develop action plans to improve clinical outcomes.
• Understand, disseminate and communicate trends in quality and safety data.
• Explain the meaning of process and outcome data and how it reflects success in performance improvement.
• Identify, implement and monitor action plans to address opportunities for improvement.
• Promotes a culture of safety; assists with the Patient Safety Culture Survey and action plan.
• Helps develop project plans and facilitates improvement in our risk reduction initiatives.
• Oversees the training, monitoring of event submissions, event trends and action plans as it relates to quality patient safety.
• Responds to serious safety events and communicates to practices and leadership as appropriate.
• Responsible for the growth in use of high reliability strategies.
• Responsible for the creation, review, revision and communication of clinical/safety related policies.

Qualifications

• Drives Results - Consistently achieving results, even under tough circumstances.
• Customer Focus - Building strong customer relationships and delivering customer-centric solutions.
• Instills Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.
• Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
• Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
• Organizational Responsibilities - Associate complies with the following organizational requirements.

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Skills

• Administrative and supervisory skills necessary to direct a number of organization programs and supervise professional and paraprofessional staff.
• Analytical skills necessary to develop programs, evaluate projects and approve or recommend changes in policies and procedures and staffing levels that affect the Quality Management department.
• Data collection and analysis skills.
• Microsoft Office, SharePoint, and project management tracking tools.
• Interpersonal skills necessary to interact effectively with a variety of contacts within and outside the Hospital.
• Verbal and written communication skills.
• Effective presentation skills.
• Initiative, judgment, creativity and leadership abilities.
• Change management skills and the ability to network and influence.
• Consultative, team building, and group facilitative skills, as well as strong project management skills.