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Manager, Quality, Full-Time, Days
2 months ago
Position Summary
The Manager Quality, under the direction of the director of quality, is responsible for developing, coordinating, implementing, and evaluating the continuous quality improvement activities for the quality program. Facilitates and monitors patient safety activities and acts as a resource to the quality team. Responsible for educating on best practice standards of care, promoting continuous readiness, and reporting quality indicators in department meetings. Leads the quality team on continuous quality improvement projects using approved tools, designed control, validations, and ensuring adherence to agency regulations.
Duties & Responsibilities
Performs ongoing analysis of gaps and clinical barriers to care.
Collaborates with risk management to perform root cause analysis (RCA) as needed.
Oversees, coordinates, and implements regulatory activities and site reviews as required including AHCA/CMS, Joint Commission, and other regulatory agencies.
Implements quality improvement activities based on data and outcomes for the quality management within the Facility.
Ensures all departments comply with and understand the quality program, reporting elements, and regulatory requirements.
Assists in designing and implementing quality and performance improvement projects including valid and reliable indicators.
Responsible for real-time tracking, trending, interpreting, and sharing quality outcomes data along with recommended follow-up plan of action and resolution based on the highest quality outcome.
Assists in staff participation on outreach program activities to support quality and safety prevention initiatives in the community.
Coordination, monitoring, and evaluation of medical record reviews/audits.
Assists in updating, reviewing, and revising policies and procedures as needed.
Develops strong working relationships with the departments, divisional teams, and the medical staff.
Facilitates all aspects of the peer review process in collaboration with the Chairperson of the Peer Review committee and or designee.
Reviews cases referred for Peer Review.
Coordinates the Peer Review Committee meetings and other related functions of the committee.
Reviews mortalities and morbidity cases as assigned.
Maintains PI Board of the units as needed.
Performs tracers and prepares assigned units for continuous survey readiness.
Role models behaviors of service excellence and CARE values (Compassion, Accountability, Respect, and Expertise).
Performs all other related job duties as assigned.
Education
Bachelor's degree in nursing or healthcare field is required. Master's degree is preferred.
Experience
Generally requires 2 to 5 years of related experience. Supervisory experience is not required.
License/Certification
License as a professional registered nurse or any other type of healthcare practitioner license is strongly preferred. BLS, ACLS, PALS, NRP certifications are required.
Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.
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