Quality Manager

Covenant Health•Nashua, NH

16d

About The Position

The Quality Manager supports and promotes the mission and values of Covenant Health Ministry and leads quality, accreditation, certification, patient safety, and performance improvement work. The role analyzes and reports quality data internally and externally; applies analytical data management skills to improve patient safety and performance; facilitates meetings and multidisciplinary teams; engages stakeholders in change management; and identifies and mitigates barriers to sustainable improvement. The manager teaches performance improvement principles and uses quality improvement tools and best practices to redesign processes and improve outcomes. The role also advises on future data and information needs, participates in DNV Hospital Accreditation and other regulatory surveys, supports survey readiness, and serves as a partner, teacher, and coach to assigned customers. Depending on assigned program responsibilities, the role may serve as the DNV Primary Stroke Certification subject matter expert or the DNV Hip and Knee Replacement Program Certification subject matter expert. These responsibilities include coordinating certification surveys and post-survey activities, facilitating program committees and improvement work, maintaining program registries and validating chart abstraction, using analytical and statistical tools, supporting evidence-based policies and education, and collaborating with clinical leaders and teams. Stroke-related responsibilities include supporting tele-stroke problem-solving and community education; hip and knee responsibilities include supporting program performance indicators, education, and community outreach. Nursing competencies are maintained as appropriate to program requirements and patient-care-team support. The position supports Covenant Health and the Catholic Health Ministry’s mission of providing healing and care for the whole person. The ministry’s core values are compassion, integrity, collaboration, and excellence.

Requirements

Experience with regulatory and accrediting bodies.
Current computer skills, including graphics, spreadsheets, and presentation software.
Quantitative and analytical skills relevant to the role.
Current knowledge of clinical processes and operations in a health care system.
Critical-thinking and communication skills.
Project-management knowledge and skills.
Hospital quality, performance improvement, or patient safety experience.
An equivalent combination of education and experience may be substituted if it provides proficiency in the areas of responsibility.
For applicable certification coordinator duties, quality management or quality improvement experience is preferred in the posting; stroke and hip/knee program responsibilities include certification, registry, data, education, and clinical collaboration duties.

Nice To Haves

New Hampshire Registered Nurse license preferred.
Five years of clinical experience preferred.
Bachelor of Science or Bachelor of Arts strongly preferred.
Certified Professional in Healthcare Quality (CPHQ) certification preferred, or eligibility to obtain it within one year.
Quality management or quality improvement experience preferred for the DNV Stroke Coordinator and DNV Hip & Knee Coordinator responsibilities.

Responsibilities

Support and promote the mission and values of Covenant Health Ministry and the Catholic Health Ministry.
Support and lead the team in accreditation and certification programs.
Analyze and report quality data internally and externally.
Use analytical data-management skills to promote patient safety and performance improvement.
Facilitate meetings and multidisciplinary teams, applying team facilitation and change-management processes to engage others in performance improvement.
Identify and mitigate barriers that impede sustainable change.
Demonstrate and teach performance improvement principles.
Use quality improvement tools and techniques to evaluate and redesign processes for improved performance.
Use resources and current best practices to identify improvement opportunities and lead efforts toward better outcomes.
Advise on future data and information needs and resources for performance and process improvement initiatives.
Participate in DNV Hospital Accreditation, other regulatory surveys, and the hospital’s survey-readiness program.
Serve as a partner, teacher, and coach to the assigned customer base.
For stroke certification duties, serve as the DNV Primary Stroke Certification subject matter expert and coordinate and facilitate certification surveys and post-survey activities.
Facilitate the Primary Stroke Certification committee and drive program performance improvement to meet certification requirements.
Abstract stroke chart data or validate third-party abstraction, and maintain the stroke registry.
Support evidence-based, best-practice stroke policies and procedures; coordinate stroke-related education for staff, providers, and others; and participate in orientation and training.
Collaborate with the stroke program medical director or stroke team to provide community education and address tele-stroke problem-solving.
Maintain nursing competencies, as appropriate, to meet stroke certification requirements and support the patient care team.
For hip and knee certification duties, serve as the DNV Hip and Knee Replacement Program Certification subject matter expert and coordinate and facilitate certification surveys and post-survey activities.
Collaborate with the Surgical Services Director or designee to ensure the hip and knee program committee meets routinely and performance indicators meet certification requirements.
Abstract hip and knee chart data or validate third-party abstraction, and maintain the program registry.
Use data-management, analytical, and statistical tools to promote patient safety and process improvement for the Hip and Knee Replacement Program.
Support evidence-based, best-practice program policies and procedures; coordinate education for staff, providers, and others; and participate in orientation and training.
Collaborate with the hip and knee program team on community education to meet certification requirements.
Demonstrate critical thinking and problem-solving skills related to certification program responsibilities.
Perform other duties consistent with the role.