Manager (RN) - Quality
The Manager of Quality Improvement assists the DCQI in the operations of the hospital's Quality / Performance improvement program. Supports quality and process improvement efforts identified in the hospital. Responsible for data tracking/collection and trending. Coordinates, assists and advises on a variety of meetings, seminars, services and/or programs related to the overall Quality / Performance Improvement program. Coordinates hospital wide performance improvement activities under the direction of the DCQI.
- Facilitate quality improvement projects using evidence-based methodologies and performance improvement tools.
- Monitor organizational quality metrics and identify opportunities for improvement.
- Facilitate development, implementation, and evaluation of corrective action plans.
- Support Quality Assessment and Performance Improvement (QAPI) activities.
- Assist departments in achieving quality and patient safety goals.
- Analyze clinical performance data and identify trends, risks, and improvement opportunities.
- Develop and maintain quality dashboards and scorecards.
- Collaborate with operational leaders to improve outcomes related to mortality, readmissions, hospital-acquired conditions, and patient experience.
- Ensure timely and accurate reporting of quality measures.
- Promote a culture of safety and high reliability.
- Support ongoing readiness for CMS, state, and accreditation surveys.
- Monitor compliance with regulatory and accreditation standards.
- Facilitate survey preparation, mock surveys, and corrective action plan development.
- Provide education regarding regulatory and accreditation requirements.
- Present quality and patient safety data to committees and leadership teams.
- Facilitate interdisciplinary teams focused on quality improvement initiatives.
- Support medical staff quality and peer review activities
Special Skills
- Knowledge of CMS Conditions of Participation and accreditation standards.
- Understanding of quality improvement methodologies (PDSA, Lean, Six Sigma).
- Strong analytical and data interpretation skills.
- Experience with quality reporting systems and dashboards.
- Excellent communication and presentation skills.
- Ability to lead multidisciplinary teams and influence change.
- Strong project management and organizational skills.
Minimum Requirements
- Education: Bachelor’s degree or higher in a patient care-related field.
- Experience: 3 years combined experience in hospital clinical practice and Quality Management. Minimum of 1 year 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.
- Certifications/Licensure: CPHQ, CPPS, or CPHRM certification within 12 months of hire
Preferred Requirement:
- Experience: 1 year as a hospital Quality Manager
- Certifications/Licensure: Registered Nurse, CPHQ, CPPS, HACP-CMS
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