Quality Manager: Full-time (Days)

Johnson Memorial Health Services•Dawson, MN

17h

About The Position

The Quality Manager is responsible for the leadership, development, implementation, and oversight of organization-wide Quality Assurance and Performance Improvement (QAPI/QAPI-PIPP) programs across the Critical Access Hospital, Rural Health Clinic, Surgical Services, Long-Term Care, and Assisted Living settings. This position ensures compliance with all applicable federal and state regulations, including Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, Minnesota Department of Health (MDH) requirements, and other regulatory and accreditation standards. The Quality Manager serves as an organizational consultant and subject matter expert in quality improvement, systems thinking, change management, and data analytics. The role leads moderate to complex performance improvement initiatives aligned with strategic priorities, utilizing Lean, Six Sigma, PDSA (Plan-Do-Study-Act), and A3 methodologies. The Quality Manager promotes a culture of safety, regulatory readiness, and continuous performance improvement while demonstrating behaviors aligned with Johnson Memorial Health Services’ Core Values: Together, Kindness, and Trust. Days/Hours: M-F / 1.0 FTE FLSA Status: Exempt ESSENTIAL FUNCTIONS Quality & Performance Improvement Provide strategic oversight of organization-wide Quality Assurance and Performance Improvement (QAPI) programs in accordance with CMS Conditions of Participation for Critical Access Hospitals and Long-Term Care. Lead and coordinate Quality Improvement Performance Improvement (QIPI) and Performance Improvement Plan Projects (PIPP). Serve as quality consultant, facilitator, and project manager for moderate to complex performance improvement initiatives aligned with organizational strategic goals. Develop and support a standardized performance improvement framework across the organization. Utilize Lean, Six Sigma, PDSA, A3 thinking, and change management methodologies to drive measurable improvements. Establish appropriate performance metrics, monitoring plans, and control plans to ensure sustainability and hardwiring of improvements. Identify and remove barriers to project success or escalate appropriately to leadership. Mentor and coach leaders and teams in improvement science, project management, group facilitation, and systems thinking. Develop, implement, and monitor quality dashboards and performance metrics across all service lines. Ensure integration of quality initiatives across hospital, clinic, surgical services, long-term care, and assisted living. Monitor and report on: Minnesota Community Measures HCAHPS and CAHPS surveys CMS Hospital Compare and Care Compare metrics CMS 5-Star Quality Rating System Minnesota Nursing Home Report Card measures Analyze trends and identify opportunities for improvement in clinical, operational, and patient experience outcomes. Regulatory Compliance & Accreditation Ensure compliance with: CMS Conditions of Participation (Critical Access Hospital and LTC) Minnesota Department of Health regulations HIPAA privacy and security standards OSHA and workplace safety standards Serve as primary liaison during regulatory surveys, audits, and inspections. Lead preparation for state and federal surveys and coordinate corrective action plans. Ensure required quality metrics for accrediting and regulatory bodies are available to appropriate stakeholders. Oversee policy review and updates to maintain regulatory compliance. Monitor and respond to quality indicators related to infection prevention, medication safety, patient safety events, and risk management. Committee Oversight & Reporting Organize, facilitate, and maintain documentation for: Professional Activities Committee (PAC) meetings Quarterly Quality Assurance Department meetings Monthly Care Center QAPI meetings Quarterly Assisted Living Quality Assurance meetings Prepare and present quality reports to: Management Team Medical Staff Senior Leadership Team Board of Directors Ensure accurate documentation of committee minutes and regulatory reporting requirements. Data Management & Analytics Gather, validate, and maintain statistical reports for hospital, clinic, surgical center, and senior living services. Develop meaningful data visualizations and executive-level dashboards. Utilize EPIC and PCC EHR and other data systems to extract, analyze, and report quality metrics. Support leaders in identifying appropriate data sources and defining meaningful measures. Collaborate with IT and clinical leadership to ensure data integrity and actionable reporting. Ensure data integrity, accuracy, and appropriate interpretation for decision-making. Conduct second-level data analysis to support root cause analysis and problem-solving initiatives. Leadership & Collaboration Serve as a quality subject matter expert and advisor to leadership and department managers. Partner with leaders to select, implement, and sustain improvement solutions. Promote a culture of high reliability, accountability, and patient-centered care. Participate in and/or lead cross-functional performance improvement projects. Attend local and regional meetings (e.g., Medi-Sota, MN Rural Health Cooperative, and other trade associations) as directed. Provide education and training related to quality methodologies, patient safety, regulatory compliance, and change management. Demonstrate strong facilitation skills in leading meetings, improvement events, and workgroups. Other Duties Perform additional duties as assigned to support organizational objectives. STANDARD REQUIREMENTS Supports the Mission, Vision and Values at Johnson Memorial Health Services. Promotes an environment that ensures the privacy, dignity, rights, and well-being of all patients, residents, and tenants. Maintains strict confidentiality of patient, resident, employee, and organizational data. Ensures compliance with: Safety policies, universal precautions, fire/safety/disaster plans, and risk management programs. HIPAA privacy and security regulations. All federal, state, and local laws. Anti-harassment and non-discrimination policies. Demonstrates strong teamwork by: Collaborating effectively with interdisciplinary teams. Communicating tactfully in sensitive situations. Addressing complaints and concerns professionally and promptly. Promoting positive public relations. Completes required in-services, annual education, and mandatory training. QUALIFICATIONS Education and Experience Associate degree or Bachelor’s degree in Nursing or related clinical field with progressive quality leadership experience. (Required) 3–5 years of healthcare quality improvement and/or clinical leadership experience (Required) Experience leading moderate to complex performance improvement projects (Required) Experience in Critical Access Hospital and/or Long-Term Care regulatory environments (Preferred) Experience using EPIC and PCC EHR (Preferred) Knowledge of HIPAA privacy regulations and application (Preferred) Required Licenses Registered Nurse (RN) preferred Licensed Practical Nurse (LPN) considered Current MN licensure if applicable Lean, Six Sigma Green Belt certification, or equivalent quality improvement certification (Preferred) Skills, Abilities, and Knowledge Strong knowledge of: CMS Conditions of Participation (CAH and LTC) Minnesota Department of Health regulations CMS 5-Star Quality Rating System Minnesota Nursing Home Report Card criteria Minnesota Community Measures and HCAHPS Demonstrated expertise in: Lean, Six Sigma, PDSA, and A3 methodologies Change management and systems thinking Project management and facilitation Measurement definition and data analysis Knowledge of medical terminology, diagnosis and procedure coding Proficiency in EPIC and PCC EHR, Microsoft Office Suite (Excel, PowerPoint, Word), and project management tools Ability to interpret complex clinical, operational and financial data Strong analytical, organizational, and problem-solving skills Exceptional meeting facilitation and presentation skills Strong change management, negotiation, and conflict resolution skills Excellent written and verbal communication skills Ability to lead change and influence across multiple service lines Demonstrated commitment to customer service excellence Ability to work both independently and collaboratively Maintains strict confidentiality and regulatory compliance Travel Minimal travel may be required (up to 5%) for meetings, regulatory events, or professional development Benefits Offered for 48+ hours (.6 FTE) Medical Insurance Dental Insurance Vision Insurance Life Insurance Flexible Spending (FSA) Health Savings (HSA) Supplemental Insurances Retirement (401a/457 Plan) Paid Time Off Employee Sick & Safety Leave Extended Illness Bank The foregoing statements describe the general purpose and responsibilities assigned to this job and are not an exhaustive list of all responsibilities and duties that may be assigned or skills that may be required. JHMS is committed to the full inclusion of all qualified individuals. As part of this commitment, JHMS will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed, please contact the Human Resources Department. JMHS is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

Requirements

Associate degree or Bachelor’s degree in Nursing or related clinical field with progressive quality leadership experience. (Required)
3–5 years of healthcare quality improvement and/or clinical leadership experience (Required)
Experience leading moderate to complex performance improvement projects (Required)
Strong knowledge of: CMS Conditions of Participation (CAH and LTC) Minnesota Department of Health regulations CMS 5-Star Quality Rating System Minnesota Nursing Home Report Card criteria Minnesota Community Measures and HCAHPS
Demonstrated expertise in: Lean, Six Sigma, PDSA, and A3 methodologies Change management and systems thinking Project management and facilitation Measurement definition and data analysis
Knowledge of medical terminology, diagnosis and procedure coding
Proficiency in EPIC and PCC EHR, Microsoft Office Suite (Excel, PowerPoint, Word), and project management tools
Ability to interpret complex clinical, operational and financial data
Strong analytical, organizational, and problem-solving skills
Exceptional meeting facilitation and presentation skills
Strong change management, negotiation, and conflict resolution skills
Excellent written and verbal communication skills
Ability to lead change and influence across multiple service lines
Demonstrated commitment to customer service excellence
Ability to work both independently and collaboratively
Maintains strict confidentiality and regulatory compliance

Nice To Haves

Experience in Critical Access Hospital and/or Long-Term Care regulatory environments (Preferred)
Experience using EPIC and PCC EHR (Preferred)
Knowledge of HIPAA privacy regulations and application (Preferred)
Registered Nurse (RN) preferred Licensed Practical Nurse (LPN) considered Current MN licensure if applicable
Lean, Six Sigma Green Belt certification, or equivalent quality improvement certification (Preferred)

Responsibilities

Provide strategic oversight of organization-wide Quality Assurance and Performance Improvement (QAPI) programs in accordance with CMS Conditions of Participation for Critical Access Hospitals and Long-Term Care.
Lead and coordinate Quality Improvement Performance Improvement (QIPI) and Performance Improvement Plan Projects (PIPP).
Serve as quality consultant, facilitator, and project manager for moderate to complex performance improvement initiatives aligned with organizational strategic goals.
Develop and support a standardized performance improvement framework across the organization.
Utilize Lean, Six Sigma, PDSA, A3 thinking, and change management methodologies to drive measurable improvements.
Establish appropriate performance metrics, monitoring plans, and control plans to ensure sustainability and hardwiring of improvements.
Identify and remove barriers to project success or escalate appropriately to leadership.
Mentor and coach leaders and teams in improvement science, project management, group facilitation, and systems thinking.
Develop, implement, and monitor quality dashboards and performance metrics across all service lines.
Ensure integration of quality initiatives across hospital, clinic, surgical services, long-term care, and assisted living.
Monitor and report on: Minnesota Community Measures HCAHPS and CAHPS surveys CMS Hospital Compare and Care Compare metrics CMS 5-Star Quality Rating System Minnesota Nursing Home Report Card measures
Analyze trends and identify opportunities for improvement in clinical, operational, and patient experience outcomes.
Ensure compliance with: CMS Conditions of Participation (Critical Access Hospital and LTC) Minnesota Department of Health regulations HIPAA privacy and security standards OSHA and workplace safety standards
Serve as primary liaison during regulatory surveys, audits, and inspections.
Lead preparation for state and federal surveys and coordinate corrective action plans.
Ensure required quality metrics for accrediting and regulatory bodies are available to appropriate stakeholders.
Oversee policy review and updates to maintain regulatory compliance.
Monitor and respond to quality indicators related to infection prevention, medication safety, patient safety events, and risk management.
Organize, facilitate, and maintain documentation for: Professional Activities Committee (PAC) meetings Quarterly Quality Assurance Department meetings Monthly Care Center QAPI meetings Quarterly Assisted Living Quality Assurance meetings
Prepare and present quality reports to: Management Team Medical Staff Senior Leadership Team Board of Directors
Ensure accurate documentation of committee minutes and regulatory reporting requirements.
Gather, validate, and maintain statistical reports for hospital, clinic, surgical center, and senior living services.
Develop meaningful data visualizations and executive-level dashboards.
Utilize EPIC and PCC EHR and other data systems to extract, analyze, and report quality metrics.
Support leaders in identifying appropriate data sources and defining meaningful measures.
Collaborate with IT and clinical leadership to ensure data integrity and actionable reporting.
Ensure data integrity, accuracy, and appropriate interpretation for decision-making.
Conduct second-level data analysis to support root cause analysis and problem-solving initiatives.
Serve as a quality subject matter expert and advisor to leadership and department managers.
Partner with leaders to select, implement, and sustain improvement solutions.
Promote a culture of high reliability, accountability, and patient-centered care.
Participate in and/or lead cross-functional performance improvement projects.
Attend local and regional meetings (e.g., Medi-Sota, MN Rural Health Cooperative, and other trade associations) as directed.
Provide education and training related to quality methodologies, patient safety, regulatory compliance, and change management.
Demonstrate strong facilitation skills in leading meetings, improvement events, and workgroups.
Perform additional duties as assigned to support organizational objectives.
Supports the Mission, Vision and Values at Johnson Memorial Health Services.
Promotes an environment that ensures the privacy, dignity, rights, and well-being of all patients, residents, and tenants.
Maintains strict confidentiality of patient, resident, employee, and organizational data.
Ensures compliance with: Safety policies, universal precautions, fire/safety/disaster plans, and risk management programs. HIPAA privacy and security regulations. All federal, state, and local laws. Anti-harassment and non-discrimination policies.
Demonstrates strong teamwork by: Collaborating effectively with interdisciplinary teams. Communicating tactfully in sensitive situations. Addressing complaints and concerns professionally and promptly. Promoting positive public relations.
Completes required in-services, annual education, and mandatory training.