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Clinical Quality Manager

3 months ago

Washington, Washington, D.C., United States MEDSTAR HEALTH Full time

General Summary of Position

The Clinical Quality Manager position reports directly to the Director of Quality Resources and will be mentored by more senior staff as needed. Leads and/or facilitates patient safety and quality improvement projects in accordance with the annual Quality and Safety Plan. Provides support and guidance to organizational leaders and clinicians in accordance with the Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff. Facilitates and/or promotes organizational regulatory compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS).

Experience in Womens Services (Labor & Delivery and Post Partum preferred).

This is a hybrid position (3 days on campus) and 2 days working remote).

Primary Duties and Responsibilities

Leads and/or facilitates patient safety and quality improvement projects - Quality and Safety Council (QSC): A) Works in collaboration with the VP, Quality, Safety and Risk to direct the priorities of QSC. B) Responsible for guiding departments and teams on reporting requirements of the QSC. C) Coordinates and plans monthly meeting priorities and assures reports and follow-up action items are assigned. Leads and/or facilitates patient safety and quality improvement projects - Interdisciplinary process improvement teams: A) Teaches and coaches clinical and organizational leaders to direct and manage PI teams using quality methods and tools. (Plan, Do Study, Act (PDSA), Root Cause Analysis (RCA), Failure Modes and Effects Analysis (FMEA). B) Participates in Safety Event Reviews and subsequent action planning teams. C) Serves as internal consultant / facilitator to groups / Interdisciplinary Process Improvement Teams working on quality initiatives, providing guidance and support to plan, implement, and coordinate clinical improvement projects. D) Analyzes process and clinical outcomes data and benchmarks results with comparable organizations. E) Researches and applies evidence-based and best practice models to guide project planning and implementation of interventions. F). Evaluates the work groups output and outcomes and provides feedback to the teams on their performance.Leads and/or facilitates patient safety and quality improvement projects - Patient Safety: A) Participates in the ongoing coaching of associates related to the culture of safety and reporting of patient safety events. B) Participates in the oversight of PSEMS modules with subsequent recategorization and/or re-routing to appropriate leadership for mitigation and follow-up. C) Through ongoing monitoring, collection and evaluation of data recommends and facilitates implementation of actions to improve quality and patient safety.Provides management support and guidance to clinical and organizational leaders in accordance with Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff: A) Assists clinical department and section chairs in the development and implementation of comprehensive clinical and performance improvement peer review programs that are data driven and evidenced based. Provides management support and guidance to clinical and organizational leaders in accordance with Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff: B) Responsible for maintaining the integrity and flow of confidential information that is used for peer review, focus professional practice evaluation (focus review), ongoing professional practice evaluation (OPPE) and reappointments for clinical departments.Provides management support and guidance to clinical and organizational leaders in accordance with Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff: C) Aggregates and analyzes data from clinical and organizational databases for the purpose of clinical improvement, quality improvement and patient safety and to support the peer review process.Facilitates and/or promotes organizational regulatory readiness and compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS): A) Facilitates actual and mock licensure and accreditation surveys. Facilitates and/or promotes organizational regulatory readiness and compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS): B) Provides quality improvement education to new associate orientation as required to comply with regulatory requirements. Facilitates and/or promotes organizational regulatory readiness and compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS): C) Maintains current knowledge of standards, rules and regulations as mandated by TJC, DOH, CMS and other quality organizations.

Minimum Qualifications
Education

  • Bachelor's degree in Nursing, with additional training in quality improvement processes required

Experience

  • 3-4 years of clinical or operational experience in an acute care hospital required as an RN
  • 1-2 years of collective experience in a healthcare quality management/systems and patient safety required
  • Experience as a team leader/ facilitator with demonstrated problem-solving skills; communication skills to effectively write reports and make formal presentations required. Women and Infant Nursing Experience Strongly Preferred

Licenses and Certifications

  • Bachelor's Degree in Nursing, Standing member of a healthcare quality improvement or patient safety professional society within 1 Year required
  • CPHQ - Certified Professional in Healthcare Quality within 1-1/2 Yrs required or
  • Certif Patient Safety Officer - CPSO within 1-1/2 Yrs required or
  • Lean Sigma within 1-1/2 Yrs required or
  • Other American Society for Quality (ASQ) certification or relevant credential within 1-1/2 Yrs required

Knowledge, Skills, and Abilities

  • Understanding of project management and be able to utilize project management concepts and tools as appropriate
  • Communication skills to effectively write reports and make formal presentations

Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

  • Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
  • Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
  • Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
  • More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.