Manager-Quality and Performance Improvement

Overview

Job Summary

The quality and accreditation manager provides oversight for the quality and performance improvement activities within the organization. This role assists with development and execution of the strategic plan for quality and safety. Assists in improving the culture of safety by providing support and content expertise to entity leadership on regulatory, accreditation, quality improvement, and patient safety matters. Assists with system level initiatives that will impact the entity and system with respect to disease specific projects, accreditation, and overall performance improvement initiatives.

Responsibilities

• Provides support for an ongoing entity regulatory/accreditation readiness program which enhances quality and patient safety through standards compliance.
• Collaborates with entity leadership such as Quality Director, CEO, CNO, and Quality to address entity requests for assistance in integrating quality improvement efforts, regulatory/accreditation compliance, and operations.
• Assists with A3 and strategic planning efforts to determine entity priorities for work each year and on-going.
• Participates in entity and system performance improvement projects, initiatives, and provides insight for the teams on strategies to achieve the desired goals.
• Serves as a knowledge expert on accreditation/regulatory requirements from Joint Commission, CMS, state agencies, and accrediting bodies (i.e. ACC).
• Educates entity leaders and assists with system accreditation and quality initiatives to meet requirements and enhance patient outcomes.
• Facilitates various committees associated with quality and performance improvement i.e. QAPI
• Assists Director with oversight of hospital benchmarking programs including CMS and LeapFrog
• Provides assistance to quality coordinators with their respective programs and responsibilities.
• Monitors and implements new regulatory and accreditation requirements as needed to maintain compliance.
• Coordinates communication to corporate counterparts as needed for maintenance of quality and accreditation processes.
• Provides coaching, mentoring, and resource for the quality department in collaboration with director.

Specifications

Experience

Minimum Required

• 5 years healthcare experience in hospital setting; previous quality experience preferred/encouraged
• Bachelor's degree in healthcare or related field required; Master's preferred
• RN license required

Preferred/Desired

Education Minimum Required

• Graduate of an accredited school of nursing. BSN required.

Preferred/Desired

• MSN

Training

Minimum Required

Preferred/Desired

Special Skills

Minimum Required

• Computer literacy. Windows desktop applications. Excellent interpersonal skills

Preferred/Desired

• Database data entry and/or management experience. Statistical knowledge, and Quality improvement or patient safety knowledge and experience.

Licensure

• Current Tennessee Licensed Registered Nurse

Minimum Required

• RN

Preferred/Desired