Manager of Quality and Safety

Trinity Health • Davenport, IA

1d • Onsite

About The Position

The Manager of Quality and Safety is responsible for managing the quality and safety programming at the local ministry level. This role involves collaborating with the ministry’s executive team, leadership, providers, and colleagues to foster high quality standards and achieve excellent outcomes. A key component of the role is leading and implementing strategies in quality and safety. The position holds accountability for quality, patient safety improvement, culture of safety (TogetherSafe), and infection prevention. The manager works closely with local leadership, including the President, COO, CNO, and CMO, to ensure the highest levels of quality and safety. The role embodies the MercyOne (Trinity Health) mission, vision, and core values, demonstrating them in all behaviors, practices, and decisions. The manager leads and oversees quality, patient safety, and infection prevention with a focus on high reliability principles and striving for zero harm. They implement a quality performance improvement plan that complies with CMS and TJC regulations and standards, in collaboration with local executive and leadership teams, quality improvement committees, the medical executive committee, and the board of trustees/directors, aligning with ministry strategies. The manager works with leadership, providers, nursing staff, and experts to develop and implement quality and safety strategies that ensure high quality outcomes and patient safety. They provide direct supervision and development for quality, safety, and infection prevention staff. The manager leads and participates in committees related to quality and safety, identifying areas of focus and collaborating to address findings proactively. They lead continuous improvement activities to excel in CMS value-based programs, commercial carrier pay-for-performance programs, and The Joint Commission quality measures and regulatory requirements. The manager also leads continuous improvement efforts to achieve recognition from outside rating organizations such as CMS, Leapfrog, Healthgrades, and Blue Distinction. They collaborate with leaders in accreditation, risk management, customer experience, and performance excellence to provide support for improvement. The manager develops quality excellence systems integrating LEAN and other methodologies, using data-driven approaches focused on quality improvement. They provide oversight, support, and consultative services to quality improvement teams. The manager works with hospital leadership to enhance the culture of safety, including a “Just Culture” and “TogetherSafe,” and supports opportunities for improvement in cause analyses, HFMEA, and PSO initiatives. They oversee clinical data gathering and analytics, ensuring the accuracy of scorecards and dashboards. The manager promotes an environment of shared leadership and decision-making. They maintain knowledge of applicable laws, regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, and other policies to ensure ethical and professional behavior. The role supports evidence-based practice, innovation, and research, and participates in the clinical contracting process. The manager contributes to the quality process by evaluating medical staff performance, including focused and ongoing professional practice evaluation reviews. They stay aware of and respond to issues related to ethnic, cultural, and diversity changes, political and social influences, financial and economic issues, the aging of society, and ethical issues in healthcare. Other duties consistent with the purpose of the job may be assigned.

Requirements

• Bachelor’s degree in nursing, health administration or related field required.
• Iowa licensure as a Registered Nurse.
• Requires a minimum of five (5) years of hospital experience in quality and/or safety, preferably in a progressive leadership role/manager level.
• National certification in quality/safety required or to be acquire within 2 years of hire.
• Member of a professional nursing organization.
• Demonstrated expertise in the use of performance improvement methodology/tools.
• Must be able to use computers for documentation and other relevant activities.
• Demonstrates specific knowledge related to software programs such as event reporting systems, government reporting systems, and other appropriate software programs.
• Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools.

Nice To Haves

• Master’s degree preferred.
• LEAN Six Sigma certification preferred.
• Helpful to have experience with PowerChart/EPIC or similar tool.

Responsibilities

• Manage at the local ministry level the quality and safety programming.
• Work collaboratively with the ministry’s executive team, leadership, providers, and colleagues to ensure high quality standards are cultivated in an environment of excellence, and outcomes are achieved.
• Lead and implement strategies in quality and safety.
• Oversee the areas of quality, patient safety improvement, culture of safety (TogetherSafe), and infection prevention.
• Collaborate with local leadership (President, Chief Operating Officer (COO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO)) to assure the highest levels of quality and safety.
• Lead and effectively manage with oversight the areas of quality, patient safety (inclusive of the culture of safety (TogetherSafe) work) and infection prevention with high reliability principles and persistent mindfulness toward zero harm.
• Implement a quality performance improvement plan that meets Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) regulations and standards, in conjunction with the local executive team, leadership team, quality improvement committees (QICs), medical executive committee, and the board of trustees/directors and in alignment with the ministry’s strategies.
• Work collaboratively with leadership, providers, nursing staffs, and experts in developing and implementing quality and safety strategies that achieve high quality outcomes and safety for the patient population.
• Provide direct supervision of the quality, safety and infection prevention staff as assigned and assists in their development and competency.
• Provide leadership and/or participates in committees related to quality and safety inclusive of quality councils, board quality committees, and QICs.
• Identify quality and safety areas of focus and works collaboratively to address findings proactively, that results in high quality and safe care.
• Lead continuous improvement activities to achieve and sustain excellence in CMS value-based programs, pay for performance programs of commercial carriers, and The Joint Commission in areas of quality measures and regulatory requirements.
• Lead and manage continuous improvement toward achieving excellent outcomes and recognition in regard to outside “rating” organizations, including (not all inclusive) CMS, Leapfrog, Healthgrades, Blue Distinction, etc.
• Actively collaborate with leaders of accreditation, risk management, customer experience, and performance excellence to provide identified and needed support for improvement.
• Develop quality excellence systems that integrate LEAN and other methodologies as appropriate that are data-driven and focused on quality improvement.
• Provide appropriate oversight, support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams.
• Work in collaboration with hospital leadership in improving the culture of safety that includes the concept of a “Just Culture” and “TogetherSafe”.
• Recommend and support opportunities for improvement on cause analyses (apparent cause, root cause, common cause), Healthcare Failure Modes and Effects Analysis (HFMEA), and Patient Safety Organization (PSO) initiatives in collaboration with risk management.
• Oversee clinical data gathering/analytics ensuring accuracy of scorecards/dashboards for internal and external customers.
• Promote an environment of shared leadership and decision-making.
• Maintain a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
• Support evidence-based practice, innovation and research.
• Participate in the clinical contracting process, consistent with legal and regulatory requirements.
• Contribute to the quality process in evaluating medical staff performance, inclusive of the focused and ongoing professional practice evaluation review process.
• Maintain awareness of and respond to issues in areas including the following: ethnic, cultural and diversity changes in the population, political and social influences, financial and economic issues, the aging of society, and ethical issues related to healthcare.
• Perform other duties consistent with the purpose of the job as directed.

Benefits

• Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager