Job Description

Employment Type:

Full time

Shift:

Day Shift

The purpose of the Manager of Quality and Safety is to manage at the local ministry level the quality and safety programming. The individual works collaboratively with the ministry’s executive team, leadership, providers, and colleagues to ensure high quality standards are cultivated in an environment of excellence, and outcomes are achieved. Leading and implementing strategies in quality and safety are a key component of the role.

The role has accountability for the following departments/functions: quality, patient safety improvement, culture of safety (TogetherSafe), and infection prevention. The manager collaborates with local leadership (President, Chief Operating Officer (COO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO)) to assure the highest levels of quality and safety.

The manager reports directly to the MercyOne RHM Director of Quality and Safety of Hospitals with an indirect reporting relationship to the local CMO (President in the absence of a CMO).

• Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) m ission, vision, core values, actions and promise in behaviors, practices, and decisions.

• Leads and effectively manages with oversight the areas of quality, patient safety (inclusive of the culture of safety (TogetherSafe) work) and infection prevention with high reliability principles and persistent mindfulness toward zero harm.

• Implements a quality performance improvement plan that meets Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) regulations and standards, in conjunction with the local executive team, leadership team, quality improvement committees (QICs), medical executive committee, and the board of trustees/directors and in alignment with the ministry’s strategies.

• Works collaboratively with leadership, providers, nursing staffs, and experts in developing and implementing quality and safety strategies that achieve high quality outcomes and safety for the patient population.

• Provides direct supervision of the quality, safety and infection prevention staff as assigned and assists in their development and competency.

• Provides leadership and/or participates in committees related to quality and safety inclusive of quality councils, board quality committees, and QICs. Identifies quality and safety areas of focus and works collaboratively to address findings proactively, that results in high quality and safe care.

• Leads continuous improvement activities to achieve and sustain excellence in CMS value-based programs, pay for performance programs of commercial carriers, and The Joint Commission in areas of quality measures and regulatory requirements.

• Leads and manages continuous improvement toward achieving excellent outcomes and recognition in regard to outside “rating” organizations, including (not all inclusive) CMS, Leapfrog, Healthgrades, Blue Distinction, etc. Actively collaborates with leaders of accreditation, risk management, customer experience, and performance excellence to provide identified and needed support for improvement.

• Develops quality excellence systems that integrate LEAN and other methodologies as appropriate that are data-driven and focused on quality improvement.

• Provides appropriate oversight, support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams.

• Works in collaboration with hospital leadership in improving the culture of safety that includes the concept of a “Just Culture” and “TogetherSafe”. Recommends and supports opportunities for improvement on cause analyses (apparent cause, root cause, common cause), Healthcare Failure Modes and Effects Analysis (HFMEA), and Patient Safety Organization (PSO) initiatives in collaboration with risk management.

• Oversees clinical data gathering/analytics ensuring accuracy of scorecards/dashboards for internal and external customers.

• Promotes an env ironment of shared leadership and decision -making

• Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

• Supports evidence-based practice, innovation and research. Participates in the clinical contracting process, consistent with legal and regulatory requirements.

• Contributes to the quality process in evaluating medical staff performance, inclusive of the focused and ongoing professional practice evaluation review process.

• Maintain awareness of and respond to issues in areas including the following: e thnic, cultural and diversity changes in the population, p olitical and social influences, f inancial and economic issues, the aging of society, and ethical issues related to healthcare

• Perform other duties consistent with the purpose of the job as directed.

General Requirements:

• Bachelor’s degree in nursing, health administration or related field required (Master’s degree preferred).

• Iowa licensure as a Registered Nurse.

• Requires a minimum of five (5) years of hospital experience in quality and/or safety, preferably in a progressive leadership role/manager level.

• National certification in quality/safety required or to be acquire within 2 years of hire. LEAN Six Sigma certification preferred.

Special Skills, Competencies, and Aptitudes:

• Member of a professional nursing organization.

• Demonstrated expertise in the use of performance improvement methodology/tools.

• Must be able to use computers for documentation and other relevant activities. Demonstrates specific knowledge related to software programs such as event reporting systems, government reporting systems, and other appropriate software programs. Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools. Helpful to have experience with PowerChart/EPIC or similar tool.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.