Manager Quality

Job Summary:
Responsible for the implementation and management of the Performance Improvement (PI) plan and maintaining compliance with Joint Commission and relevant State and Federal regulations related to quality monitoring and performance improvement. Oversees the day-to-day operations of the Quality Management staff.

Job Details:

• Assists in the design, planning, implementation, and coordination of Quality Management, Patient Safety, and Performance Improvement activities for the assigned hospital(s) and medical staff departments, committees, divisions, service lines, and functions.

• Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to activities focused on clinical quality improvement.

• Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., including data collection and reporting of process and outcome measures.

• Maintains current knowledge of accreditation and licensing requirements and serves as a resource to staff on these regulations to improve outcomes management and ensure compliance.

• Assists with regulatory readiness and survey preparation activities, including mock survey tracers.

• Provides consultation and assists physicians, ancillary, and nursing departments with regulatory compliance issues.

• Supports implementation of regulatory initiatives.

• Provides leadership to the Quality Management Department, including hiring, supervising, and monitoring staff performance and productivity.

• Contributes to the budgeting process.

• Educates and trains staff and physicians in quality improvement, including aggregation and analysis, action planning, and reporting of performance data.

• Works in collaboration with hospital leadership and medical staff to meet goals established in the Performance Improvement plan.

Minimum Qualifications:

Required Education and Experience

• Bachelor’s degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree

• Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization’s Quality Improvement Program

• Minimum of two (2) years of clinical, patient care experience or equivalent

• Experience with quality improvement methodology and data analysis

• Experience developing and implementing clinical, service, and operational process improvement initiatives, both small and large scale

Required Licensure and Certifications

• Current state license in a clinical field; five (5) years’ experience in Quality Management can be used in lieu of state license

• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required

Required Minimum Knowledge, Skills, Abilities, and Training

• Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN)

• Current knowledge of data reporting and regulatory requirements for acute and ambulatory care services (e.g., state, federal, local regulations; Joint Commission, etc.)

• Understands the importance of striving toward a zero-defect goal and ability to establish methods and metrics that deliver targeted standards for products and services

• Ability to manage collaboratively and coach others to achieve optimal performance; delegate effectively; praise/reward contributions; define clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary

• Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations

• Supervisory and/or management experience

• Ability to work well under pressure and respond to changing needs and complex environments

• Excellent communication skills (oral and written), including presentation style and the ability to concisely present data to leaders, clinicians, and staff at all levels of the organization

Dignity Health Woodland Memorial Hospital is Yolo County’s largest health care provider, serving the community since 1905. Woodland Memorial Hospital is a 108-bed acute care facility offering the most comprehensive range of health care services in Yolo County, including inpatient and outpatient surgical services, family birth center/labor and delivery, emergency services, home health services, palliative care, inpatient mental health services, sleep disorders center and cancer care services. With strong ties to our community, we believe in providing compassionate, high-quality health care to you and your family, close to home. Woodland Memorial Hospital is part of Dignity Health, one of the nation’s largest health care systems with a 22-state network. For more information, please visit our website here at www.dignityhealth.org/woodland.

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