Manager Quality Patient Safety

Catholic Health Initiative Lexington , KY 40598

Posted 4 months ago

Position Type: Regular

Scheduled Hours per 2 week Pay Period: 80


Job Summary / Purpose

Reporting to the President CEO, the Manager of Quality and Patient Safety is responsible for the supervision of a facility-based comprehensive quality and safety program. The manager implements and evaluates quality, safety and experience strategies to ensure a well-planned and systematic program for the facility. The Manager implements effective programs, ensuring consistency of best practice implementation and providing oversight and ongoing performance monitoring and action planning on key standardized quality and safety metrics. The Manager leads the efforts to develop and implement standardized plans, processes, structures, strategies and tools for planning and coordinating the daily operations of the Quality department. The Manager helps ensure continual compliance with regulations and standards set for by Joint Commission and accrediting bodies. In collaboration with Clinical Leadership, the manager supports a comprehensive program to improve

patient outcomes and minimize patient harm through the implementation of processes and systems that

support a consistent, standardized culture of quality and safety.

The Manager identifies the need for educational programs related to quality and safety and serves as an internal consultant and subject matter expert to the facility based medical staff, administration, hospital departments and committees to carry out functions related to Quality and Safety. The Manager oversees the day to day operations of the Quality team, influencing and facilitating aspects of evidence based practice and performance improvement with interdisciplinary teams, physicians, clinical leadership and direct care staff. The Manager provides oversight of the department's quality and patient safety staff and ensures that communication venues and committee forums are in place to ensure mechanisms for reporting and information sharing. The position facilitates the establishment of a data driven culture in the clinical quality and operational areas.

The Manager of Quality and Patient Safety provides collaborative oversight of the work product that

includes Clinical Performance Improvement, Infection Prevention, Accreditation and Regulatory

Compliance, Quality Improvement (peer review), Risk Management and Data Analytics / Abstraction /

Reporting operations.

The Manager monitors all infection control practices at Continuing Care Hospital. Work and communicate frequently with Hospital Epidemiologist on continued quality improvement needs and any IC needs. Reporting any concerns to appropriate organizations and timely reporting of mandated criteria to the appropriate agencies as outlined in the IC policies. Works closely with host facility on IC practices and updates.

The Manager submits CMS Care Data Set submissions as required by CMS to include all mandatory components. Timely submission of Care Data Sets as set forth by CMS. Stays current with CMS requirements and communicates any changes or needs to CMS requirement to leadership team.

The Manager coordinates with other operations and Medical Staff leaders the activities of the department related to Quality Performance Improvement and Clinical Patient Safety and Infection Control.

Essential Key Job Responsibilities

Global Quality & Patient Safety: Administrative Oversight:

  • Provide oversight and day to day operations for assigned department(s) and administrative

functions in all areas of quality and safety

  • Manage personnel and financial daily operations of the department, to include but not limited to:

interviewing, hiring, evaluation, disciplining and termination of staff; managing annual budgets to

ensure necessary staffing, equipment and supplies

  • Direct the work of local quality staff to ensure full compliance with regulatory and accrediting

standards and facility goals

  • Serve as a liaison to medical staff, administration and hospital departments and committees

  • Collaborate local CMO, CNO, and other leaders to achieve optimum divisional & facility specific

quality, safety and experience outcomes

  • Participate in the annual implementation, review and evaluation of the facility's quality, safety &

performance improvement plan

  • Maintain up-to-date departmental policies and procedures, protocols and guidelines

  • Provide facility oversight of data collection, management, submission and presentation for

performance improvement (PI) and patient safety initiatives as well as managing the quality plan

  • Ensure the systematic evaluation of services in accordance with the Quality / Performance

Improvement plan

  • Apply current concepts in quality and safety, high reliability and standardization

  • Maintain current knowledge of the Joint Commission and other relevant regulatory and reporting


  • Support quality standards and expectations, including ongoing monitoring and timely reporting of

meaningful results

  • Partner with facility-based leaders to implement accountability processes for outcomes

  • Identify the need for development, training and continuing education of staff

  • Demonstrate knowledge of national initiatives such as pay for performance and quality


  • Maintain knowledge of current and future trends in quality, safety, performance improvement,

accreditation and healthcare economics while being attuned to the needs of patients, team

members, physician, payers and regulatory bodies

  • Support all SafetyFirst efforts and role model expectations and techniques. Implement Safetyfirst

principles towards fostering a Culture of Quality and Safety

  • Promote National Patient Safety Goals either separately or concurrently with other projects

  • Foster local partnerships/processes with Risk Management to perform failure mode effects

analyses in identifying high risk processes and systems to proactively promote safe care

  • Foster local partnerships with Risk Management to participate in the review / investigation and

analysis of occurrence reports, causal factor data and determine action plans

  • Establish local partnerships with medical staff, clinical staff and leadership of clinical / non-clinical areas to improve core measures and quality indicators performance.

Judgments and Initiatives include process interpretation for peer review. Comprehensive knowledge of departmental functions and QM staff responsibilities. Must offer improvement suggestions with QM department processes (i.e., planning). Must demonstrate ability to communicate with multi-disciplinary teams.

Minimum Qualifications

Required Education

Sys/Div/Mkt/Local Manager Bachelor's Degree and minimum of 3 years leadership experience OR minimum of 5 years leadership experience in the discipline OR Master's Degree and no experience

Required Licensure and Certifications

Registered Nurse, clinical licensure preferred, Nationally recognized quality-related certification preferred

Required Minimum Knowledge, Skills and Abilities

Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and

Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious

reporting events, safe medical practices, and Centers for Medicare and Medicaid Services

(CMS) quality measures helpful

PREFERRED Qualifications

Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and

Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious

reporting events, safe medical practices, and Centers for Medicare and Medicaid Services

(CMS) quality measures helpful

Experience with Cerner, Allscripts, Meditech and other EHR software systems a plus

Strong Information Technology - informatics knowledge a plus.

Knowledge in Infection Control

Additional Information

  • Requisition ID: 2019-R0240023

  • Schedule: Full-time

  • Shift: Day Job

  • Market: CHI-Franciscan St. Joseph Medical Center

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Manager Quality Patient Safety

Catholic Health Initiative