Quality Assurance Manager

Under the direction and leadership of the CNO, the Quality Manager is a professional responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff and Governing Body. Facilitates performance improvement activities and CQI activities throughout the hospital. Acts as resource person to administrative team, department managers and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Maintains oversight responsibility for all performance improvement activities conducted throughout the institution. Responsibilities include but are not limited to:

• Assumes responsibility for own professional development and practice
• Develops professional goals
• Follows and adheres to all hospital policies and protocols

·        Practice within, Title 22 and Centers for Medicare and Medicaid Services (CMS) regulations, CDPH, HCAI and other regulatory bodies, accrediting body (i.e. Joint Commission, CIHQ etc.) .

·        Critical Thinking

o   Anticipates equipment and supply needs

o   Remains calm in emergent situations

o   Prioritizes and multi task

o   Time management skills

o   Flexible in dealing with change

o   Follows chain of command

• Role Model

o   Has a positive can do attitude

o   Demonstrates caring and compassion

o   Uses diplomacy in difficult situations

o   Addresses complaints in a professional manor

• Communication

o   Demonstrates the ability to clearly express ideas and thoughts verbally.

o   Demonstrates the ability to clearly express ideas and thoughts in written form.

o   Exhibits good listening and comprehension skills.                                                                                     

o   Consistently demonstrates the ability to select and use appropriate communication methods.

o   Keeps others adequately informed.       

• Customer Service

o   Handles both internal and external customer questions and complaints quickly, efficiently and politely.

o   Maintains a pleasant and professional image.

o   Handles service problems politely and efficiently, always communicating with customer throughout the processes. 

• Teamwork

o   Works at maintaining a good rapport and a cooperative working relationship with co-workers, other departments, and Supervisors.

o   Balances team and individual responsibilities.

o   Meets all team deadlines and responsibilities.

o   Listens to others and values opinions.

o   Contributes to building a positive team spirit and promotes a team atmosphere.

• Ethics, Safety and Compliance

o   Maintains regulatory requirements, including all state, federal and JCAHO regulations.

o   Maintains and ensure patient confidentiality at all times

o   Ensures compliance with policies and procedures regarding department operations, fire, and safety and infection control.

JOB DUTIES & RESPONSIBILITIES

·        Responsible for all regulatory and accreditation involving the JCAHO and the CDPH.  Ensures that the facility is in perpetual compliance with Title 22 and JCAHO regulations and standards by monitoring SSH standards of practice and providing ongoing feedback to SSH leadership and medical staff.

·        Demonstrates knowledge of current methodology and practices.  Maintains awareness of changes in the regulations and requirements by accrediting bodies.

·        Serves as the SSH Facility Corporate Compliance Officer and ensures SSH is compliant with all HIPPA, CMS, OIG and all governmental regulations to ensure ethical behavior.  Strives to execute integrity, adaptability, innovation, stewardship and excellence at the facility.

·        Responsible for clinical identification, risk evaluation and coordination of corrective action implementation related to risk issues. Provides intervention and education related to risk management issues to promote safe work practices and quality care and services; in an environment that is beneficial to the safety, health and well-being of all patients, visitors and hospital staff.

·        Serves as the Risk Manager for SSH and is accountable for managing and coordination activities of risk management to ensure that SSH maintains on optimum level of preventative risk management. 

·        Plans, develops and implements the SSH risk management program by identifying major areas of risk and evaluates mitigation methods through the performance improvement process.

·        Responsible for planning and implementing the Quality Assurance performance improvement program to meet the needs of the hospital. Oversight of Quality Assurance performance improvement and CQI activities throughout the hospital.  Facilitates performance improvement activities and CQI activities throughout the hospital.

·        Demonstrates effective organizational skills through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team and Governing Body to facilitate the hospital wide QAPI program.

·        Coordinates risk programs with all hospital departments, and administration.  Reports real and potential risk situations to the Governing Body, medical staff, administration, hospital departments and committees, as appropriate. Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services.

·        Serves, in conjunction with the SSH infection prevention nurse to ensure that all quality and benchmarking surveys that we currently submit data to are kept current and the data is submitted on time and in a manner consistent with the mission of SSH. 

·        Oversees infection surveillance, infection control rounds and monthly hand hygiene audits.

·        Responsible for SCIP data collection monitoring/tracking trends and graphing.  Educating staff and medical staff on SCIP.

·        Oversees OSHA required blood borne pathogens and needle sticks and providing staff education.

·        Assists with the Emergency Disaster Preparedness Office conducting the semi-annual disaster drills as requested by regulatory bodies. 

·        Works in conjunction with CNO for the hospital’s Emergency Disaster Preparedness in conducting disaster drills, as required by Joint Commission. Educating staff on Hospital Incident Command System (HICS) and ensuring that the hospital's emergency and safety plans are reviewed and compliant with all regulatory agencies.

·        Assist with a Hazard Vulnerability Analysis (HVAP) on an annual basis that is also compliant with the community HVA.

·        Serves as the Patient Safety Officer, in conjunction with the Facilities Safety Officer for SSH.  Responsible for a safe environment for all employees in the workplace.  Incorporates OSHA standards into the work environment.  Conducts an annual Failure Modes and Effects Analysis. 

·        Ensures all staff are properly trained in all aspects of patient care. 

·        Oversees Infection Prevention and Facilities on conducting Environment of Care Committee rounding and reporting.

·        Serves as the Patient Safety Officer. Responsible for identifying patient safety risks and hazards, ensuring appropriate mitigation of those risks, and overseeing the appropriate response to serious preventable harm events.

·        Serves as a resource for staff regarding Risk Management issues/concerns.

·        Chairs Hospital Wide Quality Committee and attends Performance Improvement, Infection Prevention meetings, Medical Staff and Leadership meetings.

·        Works in collaboration with Medical Staff and CNO to follow-up on patient complaints/grievances while maintaining data/log and reporting data to the Medical Staff Quality Committee. Submits all letters and responses according to guidelines.

·        Oversight of Quality,  Medical Staff Peer Review, Risk Management, Infection Prevention, and Medical Staff Office to ensure optimal performance and to provide direction/guidance on flow and departmental issues.

·        Collects, evaluates, follow-up on all occurrence reports; distributes relevant data regarding incidents/injuries.

·        Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.

·        Leads through change and adversity, makes the tough call when needed, builds consensus when appropriate, motivates and encourages others.

·        Listens well, diffuses conflict before it starts, and finds causes of and solutions to problems, handles difficult people.

·        Plans for and uses resources efficiently, always looks for ways to reduce costs, creates accurate and realistic budgets, tracks and adjusts budgets, contributes to budget planning.

·        Provide leadership in the design and implementation of leading edge evidence based strategies that align FSH measurements and improvement initiatives with emerging national and state requirements and opportunities related to HIT/HIE; “meaningful use”; nationally endorsed performance measures and payments reform.

·        Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, address root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, communicates decisions to others.

·        Applies clear/consistent performance standards, handles performance problems decisively and objectively, is direct but tactful, provides guidance and assistance to improve performance.

·        Conducts positive negotiations, ability to compromise, handles conflict, seeks common ground, articulates own and others goals, stays focused on positive outcome.

·        Facilitates/assists with general and professional liability claims; interfacing with defense legal counsel.

·        Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.

·        Creates and communicates long-term vision, balances short and long term goals, keeps own and team’s work aligned with overall goals, understands the market and can predict change, understands the industry and the competition, creates and adjusts strategic plans.

·        Demonstrates an ability to be flexible, organized and function under stressful situations.

·        Demonstrates awareness of the responsibilities of the position and how it interfaces with the rest of the healthcare team.  Works closely with all department members as required, is flexible to meet the needs of the department and changes in the workload.

·        Represents the organization in a positive and professional manner.

·        Resolves personnel concerns at the departmental level, utilizing the grievance process as required.

·        Effectively and consistently communicates administrative directive to personnel and encourages interactive departmental meetings and discussions.

·        Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department.

·        Other duties as assigned

JOB SPECIFICATIONS

MINIMUM EDUCATION/CERTIFICATIONS

• BSN in Nursing, MSN within 2 ½ years.
• Graduate from an accredited school or Nursing.
• Current RN licensure in State of California
• BLS certification
• ACLS certification
• CPHQ certification within 3 years.
• Additional course work in performance improvement and CQI desirable.
• Familiar with all related healthcare concepts, practices, policies and procedures.
• Knowledgeable of healthcare governing bodies, both state and federal.

PHYSICAL REQUIREMENTS

 For the purpose of the American Disability Act (ADA), this position has been assessed to identify essential and marginal functions. Tasks listed below are considered to be essential functions of the job. Reasonable accommodations may be made for individuals with qualifying disabilities in order to perform the essential function of the job.

• Work Position                                      75 % or more
• Sitting                                                  75 % or more
• Standing                                                          75% or more
• Walking                                               75% or more

Body Movements

• Lifting/Carrying up to 20lbs                 Frequency, less than 15%
• Bending and stooping                         Frequency, less than 25%
• Hand grip, wrist and digital dexterity   Frequency, 80%
• Pushing/Pulling                                   Frequency, 35%

SKILLS

• Speaking, hearing and visual acuity to receive and interpret instructions
• Verbal and written English communication skills
• Mathematical and reasoning skills
• Normal vision range. Ability to distinguish letters, numbers, and symbols
• Requires the use of office equipment, such as computer, telephones, photocopier, scanner and facsimile machine
• Ability to demonstrate clear oral and written communication skills
• Ability to communicate effectively in English, both verbally and in writing.
• Ability to maintain collaborative working relationships to ensure a positive and productive work environment.
• Able to communicate professionally at all levels within and outside of the organization.
• Able to effectively plan and prioritize work while dealing professionally and effectively with frequent interruption.
• Ability to provide exceptional customer service.
• PC competency, working knowledge of Microsoft Office Products (Word/Excel)