Manager, Quality & Patient Safety

Strategic:

1. In collaboration with the Executive Director of Quality, the Manager of Quality and Patient Safety will position OCMC as a national leader in clinical Quality performance metrics through internal and external reporting, such as Vizient Quality and Accountability Scorecard, The Joint Commission, CMS, QHIP, Leapfrog, USNWR, Disease Initiatives, and other regulatory agencies.

2. The Manager of Quality and Patient Safety will continuously assess, review, evaluate, and implement programs to expand what the organization is doing to achieve the Bold Goals and Vizient Quality and Accountability Scorecard as outlined by the MemorialCare Strategic Plan, as well as other hospital quality metrics.

3. Supports the strategic plan and the goals and direction of the performance improvement plan.

4. In collaboration with the Executive Director of Quality, the Manager of Quality and Patient Safety will advance OCMC in the High Reliability Organization (HRO) maturation journey.

5. Provides Lean Leader Certified oversight of the organization-wide performance improvement and patient safety plans for OCMC, and drives standardization in targeted process improvement initiatives.

6. The Manager of Quality of Patient Safety will evaluate aggregate data and outcomes from Performance Improvement collaboratives, ORYX/Core Measures, eCQMs, equity-focused stratification efforts, publicly reported data, and other comparative analysis.

7. In collaboration with the Executive Director of Quality, the Manager of Quality and Patient Safety will advance OCMC's patient experience.

Operations:

8. Mentoring, teaching, and coaching teams, providing feedback, support, and direction as needed; viewed as a PI resource for the entity.

9. Provides departments and service lines with the most current PI methods, assisting in seeking areas for improvement and the facilitation of projects while working with varying levels of professional, clinical, and ancillary staff.

10. Works collaboratively with leadership and physician partners across the organization in the following roles: identification and management of key performance indicators, audit workflows, action planning, and investigation.

11. Provides statistical analysis of key performance metrics and assists department leaders in the preparation and analysis of data.

12. 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.

13. Performs quality chart reviews and monitors compliance for publicly reported data and key quality performance metrics.

14. 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.

15. Participates actively in Medical Staff committees, including PIPS, and department and service line meetings

16. Provides teams with the most current PI methods and tools, including project management support.

17. Implements best practices in accordance with the hospital policies and submits presentations on behalf of MemorialCare at state and national meetings.

18. Actively participates in patient leadership rounds to assess both the patient's experience and culture of safety.

19. Develops and implements policies and procedures in compliance with regulatory requirements

20. Ensures cost-effective daily operations and allocation of resources.

21. Effectively manages members of the quality department team.

22. Hires, develops, and maintains performance and competence of department staff.

Regulatory:

23. Actively participates in Continuous Regulatory/Survey Readiness.

24. Ensures compliance with healthcare regulations and standards

25. Participates in tracer activity, clinical and/or environmental rounds when appropriate to maintain a state of continuous service readiness for regulatory surveys.

26. Oversees the completion of required action plans and ensures ongoing assessment and compliance.