Surgery Partners-posted about 1 month ago
Full-time • Manager
Onsite • Durango, CO
5,001-10,000 employees
Hospitals

If you dream of working in a state-of-the-art environment where everyone partners for a successful patient experience, you'll fit in great at Animas Surgical Hospital. We've structured our facility to help you deliver superior care to each patient-and it shows in our outstanding outcomes. With a low patient-to-nurse ratio (3:1), a near-zero infection rate, and high patient satisfaction, our hospital tops the lists of great places to receive care and to work in a healthcare job. Distinguished as one of the 100 best places to work in healthcare jobs by Becker's Hospital Review. Ranked America's #1 in overall patient satisfaction, according to a national patient survey conducted by the federal government. A full 93% of our patients gave the hospital, our physicians, and staff the highest score possible. Named 2011 Business of the Year by the Durango Chamber of Commerce. Job Summary: The Quality, Risk, and Infection Prevention Manager is responsible for developing, implementing, and maintaining comprehensive quality monitoring and reporting, risk management, and infection prevention strategies across the organization. This position ensures compliance with regulatory standards and industry best practices, promotes a culture of safety, and provides leadership and direction to effectively manage and mitigate organizational risks.

  • Analyze performance data and assigned quality measures. Identify trends, gaps, and opportunities and evaluate the need for quality improvement initiatives, policies, and procedures in line with regulatory requirements and organizational goals.
  • Collaborate with cross-functional teams to implement process improvements that enhance patient care, operational efficiency, and service quality.
  • Lead and facilitate quality committees or workgroups, ensuring consistent application of quality standards throughout the organization.
  • Monitor and evaluate the enterprise-wide risk management program in partnership with the Quality Director to identify organizational risk.
  • Analyze incident reports and partner with hospital leadership for timely follow up and closure of events.
  • Monitor for trends in events related to processes and individuals for potential quality improvement initiatives.
  • Investigate adverse events to determine root causes and develop corrective action plans.
  • Educate staff on risk prevention strategies, regulatory requirements, and best practices to promote a proactive culture of safety.
  • Review patient complaints and evaluate the need to escalate to a grievance according to CMS definitions.
  • Draft and respond to identified grievances according to hospital policy.
  • Facilitate the review of grievances at the assigned hospital committee.
  • Coordinate with legal, claims and insurance regarding high-risk events.
  • Establish, implement, and monitor infection prevention and control policies and procedures to minimize the spread of infectious diseases.
  • Lead organizational compliance with infection prevention guidelines from relevant agencies (e.g., CDC, WHO, OSHA, The Joint Commission).
  • Conduct regular infection control surveillance, audits, and risk assessments to identify areas for improvement.
  • Provide routine follow-up to identified areas for opportunity to ensure compliance with action plans.
  • Provide guidance and expertise during outbreaks or infection-related emergencies, ensuring appropriate containment and mitigation measures are in place.
  • Partner with departmental leaders to investigate and report hospital acquired conditions (e.g., SSI's, CAUTI, CLASBSI, Emerging Infections).
  • Submit required data to NHSN and ensure accurate public reporting of healthcare-associated infections.
  • In alignment with OSHA and CDC guidance, review and coordinate employee health follow up.
  • Partnering with Clinical Education, Human Resources, and Credentialing as needed.
  • Stay current with healthcare regulations, accreditation standards, and applicable laws related to quality, risk, and infection prevention.
  • Collaborate with department leaders to address deficiencies and implement corrective actions promptly.
  • Partner with clinical and administrative leaders to align departmental initiatives with organizational priorities.
  • Communicate effectively with senior leadership, providing regular updates on performance, risk status, and infection prevention efforts.
  • Collaboration with state and local public health offices.
  • Performs other duties as assigned.
  • Bachelor's degree in Nursing, Public Health, Healthcare Administration, or a related field required.
  • Minimum of 3 years of experience in Healthcare Administration, Nursing, Public Health, or a related field.
  • Demonstrated leadership experience, including facilitation of meetings, closed loop communication and follow-up, and program development.
  • Current state license as a registered nurse; current CPR certification; ACLS, PALS or TNCC certifications per policy.
  • Knowledge of healthcare regulations, accreditation standards (e.g., Joint Commission), and guidelines (e.g., CDC, OSHA).
  • Strong analytical and problem-solving skills with a proven ability to interpret data and metrics.
  • Excellent communication, presentation, and interpersonal skills to effectively engage various stakeholders.
  • Ability to manage multiple priorities, work under pressure, and adapt to a rapidly changing environment.
  • Proficiency in Microsoft Office Suite and data analysis tools.
  • Master's degree in Healthcare Administration, Nursing, Public Health, or a related field preferred.
  • health
  • dental
  • vision
  • life insurance
  • 401k with employer matching
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