The Quality Manager oversees and manages all aspects of quality assurance and quality improvement within the hospital. This role involves developing, implementing, and monitoring quality improvement initiatives to ensure compliance with regulatory standards and optimal patient care outcomes. This position collaborates with the Lakeside Medical Center administrative, clinical, and medical staff leadership, providing leadership in developing a culture of safety and, measuring the quality of care, identifying opportunities and strategies for performance improvement. This position will also serve as a Joint Commission liaison and subject matter expert for the hospital related to quality assurance and compliance with The Joint Commission standards and other regulatory agencies.
Please read the following job description thoroughly to ensure you are the right fit for this role before applying.
Leads the development and execution of quality improvement projects and initiatives. Analyze data to identify areas for improvement and implement evidence-based strategies to enhance patient outcomes. Monitor the effectiveness of implemented quality initiatives and adjust strategies as necessary.
Prepares and performs case summaries, chart audits, chart abstractions, and analyze data collected to ensure compliance and implement actions to improve patient care
Prepare and submit mandatory reports to regulatory agencies in a timely manner.
Ensure hospital practices comply with local, state, and federal regulations, including those set by the Joint Commission and other accrediting bodies.
Provides strategic oversight of proactive and reactive patient safety activities, including root cause analyses, failure mode effects analyses, and Sentinel Event alerts.
Collaborates with the Risk Management Team on the reporting, investigation, analysis, and corrective action planning on medical errors and near misses.
Creates and monitors adherence to quality-related policies, procedures, and standards
Collaborate with IT to create quality improvement dashboards and analyze relevant trends
Prepare reports and presentations on quality performance and improvement initiatives for leadership and stakeholders.
Collaborate with multidisciplinary teams in the monitoring, reporting, and improvement activities related to clinical care, operations, healthcare quality/safety initiatives, accreditation, and regulatory requirements.
Coordinates the facility’s Joint Commission accreditation activities, including leading teams and committees in compliance activities. Provides leadership education on standards and coordinates ongoing compliance review activities and corrective actions.
Participates and coordinates various committees and projects to facilitate the compliance of regulatory requirements.
Maintains readiness for unannounced agency visits and participates in various regulatory agency surveys.
Stay current on industry trends, best practices, and emerging technologies in quality assurance and healthcare delivery.
Coordinates the Patient Safety Culture Survey with leadership, analyze and trend results.
Emergency duty may be required of the incumbent including but not limited to: working in special needs or Red Cross shelters, performing other emergency duties responding to threats or disasters, man-made or natural as required.
Education:
Bachelor’s Degree in Nursing, Master’s Degree in same preferred.
Experience:
Minimum of Three to Five (3-5) years of progressive administrative leadership experience in quality and patient safety activities with demonstrated ability in design and implementation of performance improvement activities in a healthcare setting, including skillful application of continuous quality improvement and patient safety sciences. Strong understanding of regulatory requirements, accreditation standards (e.g., Joint Commission, CMS), and quality improvement methodologies (e.g., Lean, Six Sigma).
Certification:
Certification in Healthcare Quality is preferred (CPHQ). Lean Six Sigma
Licensure:
Florida State License as a Registered Nurse. Valid Florida Driver’s License.
Training:
Leadership and health care management training is preferred.