Manager Quality-Patient Safety

CHI St. Alexius Health Dickinson•Dickinson, ND

1d•Onsite

About The Position

As a Quality Improvement Manager, you will be solely responsible for administering and managing the facility's quality improvement and risk management programs. Daily, you will oversee quality initiatives, monitor performance, and drive continuous improvement for patient safety. You will also manage risk identification, assessment, mitigation, and reporting, ensuring regulatory compliance and minimizing liabilities, fostering a culture of safety and excellence. Success in this role requires a deep understanding of healthcare quality and risk management, strong analytical and leadership skills, an unwavering commitment to patient safety, and the ability to implement robust programs. Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement. Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures. Mains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers. Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues. Supports implementation of regulatory initiatives. Oversees the events reporting process, root cause analysis, and event investigation/review. Supports and encourages harm reporting throughout the organization through a non-punitive just event reporting system. Participates in system office initiatives and programs to mitigate risks identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices/care. Prepares and presents informative and actionable patient safety reports (to include patient's story of harm) to appropriate committees to include high level presentations to leadership, Medical Executive Committee and The Board.

Requirements

Bachelors Other in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree, upon hire.
Minimum of three (3) years of progressive management responsibility in an acute care setting.
One (1) year of which is related to managing an organization’s Quality Improvement Program including quality improvement methodology and data analysis.
Minimum of three (3) years of risk management, patient safety and/or other related professional experience.
Experience developing and implementing clinical, service and operational process improvement initiatives.
Minimum of two (2) years of clinical, patient care experience or equivalent.
Registered Nurse: ND, upon hire or Registered Nurse Practitioner: ND, upon hire or Dietitian: ND, upon hire or Pharmacist: ND, upon hire or Physical Therapist: ND, upon hire or Occupational Therapist: ND, upon hire or Speech Language Pathologist: ND, upon hire or Medical Radiographer: ND, upon hire or Respiratory Care Practitioner: ND, upon hire or Social Worker: ND, upon hire or Doctor of Medicine: ND, upon hire or Doctor Osteopathic Medicine: ND, upon hire.
Certified Professional in Healthcare Quality, within 24 - months or Healthcare Quality Mgmt, within 24 - months or Cert Prof Healthcare Qual, within 24 - months.

Responsibilities

Administering and managing the facility's quality improvement and risk management programs.
Overseeing quality initiatives, monitoring performance, and driving continuous improvement for patient safety.
Managing risk identification, assessment, mitigation, and reporting, ensuring regulatory compliance and minimizing liabilities.
Fostering a culture of safety and excellence.
Assisting in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) and medical staff departments, committees, divisions, service lines and functions.
Proactively coordinating and facilitating performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement.
Ensuring compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
Maintaining current knowledge of accreditation and licensing requirements and serving as a resource to staff on these regulations.
Assisting with regulatory readiness and survey preparation activities including mock survey tracers.
Providing consultation and assisting physicians, ancillary and nursing departments with regulatory compliance issues.
Supporting implementation of regulatory initiatives.
Overseeing the events reporting process, root cause analysis, and event investigation/review.
Supporting and encouraging harm reporting throughout the organization through a non-punitive just event reporting system.
Participating in system office initiatives and programs to mitigate risks identified at other hospitals.
Preparing and presenting informative and actionable patient safety reports to appropriate committees, including leadership, Medical Executive Committee and The Board.