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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