Manager, Patient Safety and Quality

Hackensack Meridian Health•Brick, NJ

About The Position

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. The Manager of Patient Safety and Quality acts in conjunction with the Director of Patient Safety & Quality to provide leadership for quality & safety improvement initiatives. Collaborates with Hackensack Meridian Health (HMH) initiative-focused groups, clinical transformation services and quality councils to achieve transformational and sustainable outcome improvements using project/program management, process and system mapping, reliability science data driven strategies, evidence based best practices and quality improvement strategies. Provides ongoing support, instruction, and leadership to meet and exceed all accreditation standards, and to ensure ongoing readiness for accreditation throughout all accredited programs. Works with the Director Patient Safety and Quality to respond to and coordinate investigation by the Joint Commission, Department of Health (DOH) and other external regulatory agencies.

Requirements

Bachelor's degree in Nursing, Healthcare or health science field or other relevant area of study.
Minimum of 5 or more years of experience in healthcare quality, patient safety, and regulatory.
Performance Improvement experience.
Understanding of the Joint Commission and regulatory standards.
Excellent written and verbal communication skills.
Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.
Certified Professional in Patient Safety.

Nice To Haves

Master's degree in nursing, health care or health science.
Certified Professional in Healthcare Quality.

Responsibilities

Orient and mentor new Department of Patient Safety and Quality team members.
Provides feedback to Director of Patient Safety and Quality on team member performance evaluations
Provide expert knowledge, leadership and mentoring in patient safety & quality initiatives utilizing safety and high reliability science.
Monitor standards of practice to ensure compliance with codes of internal and external regulatory and accrediting agencies including: a. The Joint Commission b. NJ State and Federal Codes (i.e.: DOH, OSHA) c. Professional review organizations
Chair organizational level committees/councils (i.e. Regulatory Steering Committee, Performance Improvement Committee).
Facilitates/coordinates regulatory activities throughout all accredited programs.Collaborates with staff, physicians, and administration to ensure successful regulatory surveys.
Facilitate patient safety and environment of care rounds with interprofessional collaboration with utilization of the Joint Commission AMP monitoring tool.
Lead onsite regulatory surveys to respond to and coordinate investigation by the Joint Commission, DOH and other external regulatory agencies.
Develops and implements hospital wide training to maintain compliance with Joint Commission and other regulatory standards.
Facilitate and lead highly functioning teams organized around quality & safety initiatives.
Identify improvement priorities specific to each HMH initiative-focused improvement work, clinical transformation service, or quality council based on evidence based practice, taking into consideration regulatory requirements and accrediting agencies such as CMS, Pay for Performance, The State of New Jersey Department of Health, and The Joint Commission.
Bring safety and quality events, concerns and needs to the local morning safety huddle.
Encourage event reporting and transparency related to events, concerns, needs, processes to identify precursor and safety events.
Identify & implement data driven strategies to ensure team's success.
Utilize the Quality dashboards to drive improvements by the HMH initiative-focused improvement work, clinical transformation service, or quality council.
Strategize with personnel at all levels to develop and coordinate patient safety programs.
Create and maintain timely and thorough progress reports that include key driver diagrams, run charts, Agile methods and PDSA testing documentation.
Engage all levels of caregivers and staff in advancing patient safety through HRO training, quality initiatives addressing small wins and when designing system improvement.
Develop metrics and report key quality & safety metrics to accurately demonstrate improvement in safety & quality across the medical center and network.
Provide timely, actionable feedback and reports to clinical, administrative and support staff on all safety & quality initiatives.
Ensure appropriate referral and follow up for events including escalation for regulatory reporting.
Increase transparency, reinforce high reliability and advance the safety culture by participating in and facilitating safety huddles, patient safety activities, just culture reinforcement and shared learning.
Facilitate the NPSF RCA-2 process as needed.
Effective trend analysis of performance data with comparison over time to internal and external benchmarks to identify improvement opportunities, and progress.
Attend root cause analysis meetings as specific to HMH initiative-focused group, clinical transformation service, or quality council focus area.
Direct patient and team member safety by identification of actual or potential safety issues.
Advance & enhance professional growth and development through seminars, workshops and professional networking opportunities to maintain and extend expertise.
Other duties and/or projects as assigned
Adheres to HMH Organizational competencies and standards of behavior.