Quality Manager

Position Summary

Under the CEO's general supervision and working within a dotted-line matrix, the Quality Manager (QM) is given the necessary authority and responsibility to oversee, facilitate and perform the necessary tasks to achieve facility and system quality goals. The QM also serves as the primary point of contact for patient safety events, compliance/ privacy and accreditation matters for the facility.

ESSENTIAL JOB DUTIES And RESPONSIBILITIES

Oversees all hospital-wide Quality Improvement (QI) activities and recommends best practices to maintain and improve projects or facility outcomes.

Adopts, implements, and maintains the organizational Quality Plan and program through monitoring, aggregation of data, and evaluation, including event report investigations, trending and analysis. Uses sound management to review such indicated processes.

Partners with Corporate Quality leaders and other Nexus Quality leaders to standardize QI efforts.

Develop effective, positive relationships with staff, leaders and physicians in order to accomplish objectives of the Nexus Quality program, serving as an ethical example of the rules of conduct and leadership.

Establishes, maintains and tracks departmental metrics and other necessary QI data and escalates deviations from goals, minimum standards or other required standards in an expeditious manner.

Ensures high risk activities and events are monitored and concurrently and/or retrospectively reviewed. Concerns involving facility performance will be professionally communicated in either written or oral presentation or both.

Educates staff and physicians regarding the Quality Improvement program and QI processes.

Prepare all necessary activities of the facility Quality Council and the Quality/Risk reports for Quality Council.

Works in partnership with the Quality physician to monitor physician performance and assist with the Medical Executive Committee and Governing Board processes.

Follows investigation procedures in response to patient safety events or accidents, including development of corrective or preventive action plans.

Work with team members in the management and development of best practices in policy development and oversee and manage the policy repository system for the facility.

Coordinates and serves as the expert and resource for all external programmatic reviews, unannounced/ announced surveys, desktop reviews and responses to regulatory agencies or health plans per policy and responds to inquiries in an immediate fashion.

Conduct corrective, preventive, and baseline audits to evaluate opportunities to improve.

Ensures ongoing review of hospital practices in order to maintain hospital licensure and accreditation.

Attends staff meetings or other facility meetings and represents the Quality of Nexus in a professional manner.

Works with facility Safety Officer in implementing and maintaining programs for patient/employee safety.

Serves as hospital representative in its relationships with outside agencies and vendors.

Performs other duties which may be required of the facility or organization from time to time.

Education

POSITION QUALIFICATIONS:

• Bachelor’s degree in nursing preferred.
• Another Bachelor’s degree with equivalent clinical experience may be considered.
  
  

Experience

• Minimum of 3-5 years of recent hospital experience in a supervisor or manager role.
• Minimum of 1 year experience in a Quality or Patient Safety role is preferred. Alternate experience will be considered on a case-by-case basis.
  
  

Licensure/Certification

• Unencumbered Registered Nurse (R.N.) license in the State of Texas or another compact state is preferred
• Basic Life Support (BLS) is required
• Certified Professional Patient in Patient Safety (CPPS) or ability to achieve within one year of hire
  
  

KNOWLEDGE, SKILLS And ABILITIES

• Extensive knowledge of health care accreditation (Joint Commission or DNV is preferred)
• Working knowledge of pediatric specialties, such as Prader Willi Syndrome and Autism
• A strong understanding of the principles, practices and analysis in a Quality Management System (QMS)
• Advanced verbal and written communication skills necessary to effectively collaborate in a team environment and make meaningful contributions to projects and assignments.