Manager - Quality Program

Presbyterian Healthcare Services•Española, NM

2d•$75,733 - $128,960•Hybrid

About The Position

Presbyterian Española Hospital is seeking a Manager for our Quality Program to lead quality improvement initiatives, regulatory readiness efforts, and patient safety programs that support exceptional clinical outcomes and operational excellence. The Manager, Quality Program serves as a key leader within the hospital, partnering with physicians, nursing leadership, and interdisciplinary teams to foster a culture of continuous improvement, patient safety, and high reliability. This role is responsible for overseeing quality metrics, accreditation readiness, performance improvement activities, regulatory compliance, and data-driven decision-making to ensure the delivery of high-quality patient care. This role will lead, design and support the quality program including clinical quality, patient safety and continuous readiness to assure quality care and regulatory compliance. Function as a SME for quality methodologies, facilitating, coaching and supporting quality initiatives. Responsible for goal initiatives, identifying appropriate solutions for clinical initiatives in a timely manner and is actively involved in process redesign and re-engineering. Assist and support PHS quality initiatives. This role is also responsible for the Infection Control, Employee Health and Case Management service programs.

Requirements

Bachelors degree in nursing or related clinical field or bachelors degree with health care experience required.
Licensed RN preferred
3-5 years experience in health care quality required
Clinical Quality experience with emphasis on clinical quality data and measurement, interdisciplinary support and performance improvement preferred.
Prior leadership experience preferred
CPPS, CPHQ or other quality certification preferred.
Skills -analytic, customer service, MS office, negotiation, presentation, reporting, verbal communication, professionalism, written communication.

Nice To Haves

Masters degree is preferred
Clinical Quality experience with emphasis on clinical quality data and measurement, interdisciplinary support and performance improvement preferred.
Prior leadership experience preferred
CPPS, CPHQ or other quality certification preferred.

Responsibilities

Develop, monitor and support the facility QAPI program to ensure it meets regulatory requirements, to include infection control, clinical quality and business indicators in conjunction with leadership and the Regional Director of Clinical Quality/Patient Safety.
Analyze QAPI data and report data to appropriate committees/groups.
Provide clinically pertinent perspective in development of clinical information and measurement processes in conjunction with the Regional Director of Quality/Safety.
Participates in the development, collection and reporting of clinical performance measurements.
Manage regulatory and accreditation preparation activities at the facility level and assist at the PHS level.
Serves as a lead contact during regulatory surveys, working with the Regional Director of Clinical Quality/Patient Safety.
Lead and assist facility in establishing and maintaining quality plans, clinical improvement, management of processes and establishing goals and objectives for clinical quality and patient safety initiatives.
Serve as a resource regarding quality theory and practice, especially as it relates to: development and evaluation of patient safety and quality indicators, application of quality methodologies to quality improvement and regulatory readiness.
Lead and support clinical quality and patient safety initiatives at the facility and participate in task forces, summits, and work groups as appropriate.
Conduct risk analysis using established techniques and strategies.
Conduct RCI/PSI or special cause investigations.
Prepare, present and maintain short term and long-range quality improvement plans, clinical outcome plans and patient safety plans.
Manage and direct a team, orient new staff.
Oversee the outcomes of orientation processes and retention of new hires.
Address areas of opportunity to meet organizational goals.
Drive financial components of department operations including budget creation, monitoring, analyzing, report variances in areas of responsibility.
Responsible for achieving established targets.