RN Clinical Quality Program Manager

HonorHealth
United States, Arizona, Scottsdale
Jan 28, 2025
Overview Looking to be part of something more meaningful? At HonorHealth, you'll be part of a team, creating a multi-dimensional care experience for our patients. You'll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let's go beyond expectations and transform healthcare together. HonorHealth is one of Arizona's largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses nine acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With more than 16,000 team members, 3,700 affiliated providers and over 1,100 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com. Responsibilities Job Summary The Clinical Quality Improvement Program Manager will facilitate multidisciplinary improvement teams and provide consultation to improve clinical processes and outcomes, eliminate unnecessary variation, and reduce the risk of harm to patients across the network and continuum. Provides ongoing evaluation of service line and/or clinical area performance, facilitates prioritization of improvement activities, and ensures successful implementation of initiatives within assigned scope. Provides operational oversight for the hospital's Medical Staff Peer Review System across the network to ensure it is instrumental in identifying, tracking and improving processes to resolve clinical performance in a manner that promotes education, improvement, and patient safety. Provides direction to ensure that clinical services are supported by the best evidence available and are provided in accordance with standards established by federal and state regulatory agencies. Draws on expertise in LEAN continuous improvement methodologies, project/change management skills, and clinical specialty expertise to analyze and drive improvement. Leads and/or facilitates clinical process improvement. Serves as a resource for assessment of clinical performance, process improvement methodologies and peer review. Collaborates and supports the implementation of evidence based clinical practices. Develops and presents information at hospital, medical staff departments and committees to demonstrate progress toward goals. Partners with service line leaders, executives, medical staff, and hospital staff regarding clinical performance improvement goals and regulatory requirements. Supports the development of specific clinical indicators for service line, clinical specialty, and medical staff quality scorecards. Serves as a resource and mentor to data support specialists and analysts in the definition/development of indicators and data displays including the application of statistical techniques. Provides ongoing assessment of clinical specialty performance and analyzes clinical process and outcome data to identify performance improvement opportunities or trends. Supports and facilitates performance improvement activities related to or resulting from peer review, OPPE, FPPE, analysis of patient safety and clinical performance measures. Facilitates prioritization of improvement activities with clinical specialty leadership while supporting alignment with the organizational goals. Evaluates and communicates the effectiveness of specific interventions. Evaluates network performance on publically reported quality measures such as Inpatient and Outpatient Quality Reporting (IQR, OQR). If applicable, Collaborates with appropriate external organizations. Collaborates with Safety/Quality Improvement teams to analyze events and near misses to identify trends and appropriate cases for peer review within the clinical specialty. Supports Safety/Quality Improvement teams by participating in root cause analyses pertinent to clinical specialty. Supports ongoing professional practice evaluation (OPPE), focused professional practice evaluation (FPPE), and peer review processes. Collaborates with medical staff in the development of accurate, meaningful physician quality profiles. Collaborates with the Clinical Performance Measurement and Reporting team to monitor database integrity validate data accuracy, and ensure the transfer of data to appropriate national and state benchmarking. Conducts and presents research to identify best practice performance measures for benchmarking opportunities. Maintains the confidentiality of highly sensitive information. Disseminates information as appropriate throughout the network, while using appropriate safeguards to prevent inappropriate use or disclosure of confidential information. In collaboration with the appropriate stakeholders, supports clinical specialty specific accreditations/designations Participates in internal audits and supports compliance with DNV process requirements. Participates in DNV and state (regulatory) site visits. Performs other duties as assigned. Qualifications Education Associate's Degree or 2 years' work related experience in healthcare or related field Required Experience 2 years clinical experience in relevant clinical area; OR Required 2 years Process and quality improvement experience Required Licenses and Certifications Registered Nurse (RN) State And/Or Compact State Licensure If RN, verified current RN AZ license or other compact state RN license. Required