The Quality Program Manager’s (QPM) role merges quality/performance improvement with day to day coordination of the hospital’s Risk Management functions. The QPM is accountable for programs related to quality and performance improvement through process and system analysis including measurement based on evidence based practice, the strategic plan, regulatory requirements and proactive management of risk and regulatory compliance throughout the Hospital. S/he oversees and is accountable for ensuring collection, maintenance, analysis, interpretation, and dissemination of quality, safety, research, and compliance data findings. S/he trains, supervises and evaluates initaitives associated with safety, risk and quality as necessary to fulfill a project goal; providing leadership, management, and facilitation of related quality improvement teams and efforts across operational departments.
Principal Duties and Essential Functions:
1. Develops and leads quality improvement programs or initiatives to effect change and accomplish the established goals and objectives of the Hospital through performance of needs assessments to identify practice/ systems issues and create/enhance processes and systems for meeting program goals and objectives
2. Ensures that risks are identified and managed to reduce institutional liability and to promote patient safety.
3. Establishes effective interdisciplinary relationships with members of clinical departments, Medical Records, Compliance, Laboratory, Information Systems, etc., whose support is necessary for the successful management of compliance, quality/performance improvement and patient safety initiatives.
4. Leads and/or participates in department activities and/or hospital committees and task forces.
5. Manages evolving mandates for external quality reporting and regulatory requirements e.g., JC, NPSGs, ORYX, Core Measures, Leapfrog, CMS/Medicare, etc.
6. Leads the development and review of policies and care standards associated with projects for the service line and/or departments.
7. Conducts investigations of sentinel/ adverse events, runs root cause analysis, and follows through on completion of action items.
8. Manages internal and external reporting requirements.
9. Keeps current with risk management trends and quality/performance methodologies.
10. Performs other related duties and responsibilities as required.
BSN Required. Master’s Degree Preferred.
Nursing License Required. Green belt in Lean strongly preferred.
Required Work Experience:
3-5 years relat