Mgr Quality Management (MHO)

Reports to the Director, Executive Director and VP of Nursing. Responsible for organizing, planning, and directing the efficient operation of quality patient care services in the daily operations of the department. Oversees the department’s quality improvement and patient safety programs, ensuring compliance with regulatory requirements and alignment with Beacon’s mission, values, and service goals. Contributes to the development / revision of policies, procedures, protocols and standards of care. Provides department leadership in Performance Improvement methods and tools, facilitates projects and workshops, monitors data for opportunities, communicates trends, and responds to safety events. Accountable for driving improvements in clinical quality, patient safety, patient satisfaction, and fostering a culture of high reliability. If Beacon Children’s Hospital specific, facilitator of SPS quality initiatives.

MISSION, VALUES and SERVICE GOALS

MISSION : We deliver outstanding care, inspire health, and connect with heart.

VALUES : Trust. Respect. Integrity. Compassion.

SERVICE GOALS : Personally connect. Keep everyone informed. Be on their team.

Key Responsibilities

Department Leadership & Administration to ensure high quality, efficient patient care :

• Observing care delivery to ensure appropriateness of nursing care.
• Reviewing patient medical records to ensure completeness of the record and appropriate documentation.
• Collaborating with the Educator to assess staff educational needs, orientation, training and skill validation.
• Recommend and implement departmental policies and standards.
• Provide leadership, guidance, and direction for quality improvement measures.

Assists with managing the overall operations of the department by :

Quality and Safety Program Management

Data and Performance Improvement

Leadership Competencies

Drives Results - Consistently achieving results, even under tough circumstances.

Customer Focus - Building strong customer relationships and delivering customer-centric solutions.

Instills Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.

Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.

Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by :

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements :

Attends and participates in department meetings and is accountable for all information shared.

Completes mandatory education, annual competencies and department specific education within established timeframes.

Completes annual employee health requirements within established timeframes.

Maintains license / certification, registration in good standing throughout fiscal year.

Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position / department.

Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.

Adheres to regulatory agency requirements, survey process and compliance.

Complies with established organization and department policies.

Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way :

Leverage innovation everywhere.

Cultivate human talent.

Embrace performance improvement.

Build greatness through accountability.

Use information to improve and advance.

Communicate clearly and continuously.

Education and Experience

Bachelor's degree or clinical degree required; master's degree preferred. Nursing experience is preferred, although candidates with non-clinical degrees, such as MBA, MPH, or MS will be considered if there is commensurate work experience in healthcare performance improvement and hospital operations. BSN preferred and 5+ years knowledge and experience in quality improvement modes, such as Lean / Six Sigma, the IHI Model for Improvement, or other comparable performance improvement strategies. Knowledge of Joint Commission, CMS and Indiana Department of Health standards / regulations is required. Knowledge of national standards and outcomes for quality, safety and healthcare Anthem Measures and Value Based Purchasing, AHRQ, Leapfrog, Experience with Root Cause Analysis and Healthcare Failure Mode and Effects Analysis.

Knowledge & Skills

Demonstrates administrative and supervisory skills necessary to direct several organization programs and supervise professional and paraprofessional staff.

Demonstrates analytical skills necessary to develop programs, evaluate projects and approve or recommend changes in policies and procedures and staffing levels that affect the Quality Management department. Demonstrate accurate, thorough data collection and analysis and have knowledge and experience of Microsoft Office, SharePoint, and project management tracking tools.

Demonstrates interpersonal skills necessary to interact effectively with a variety of contacts within and outside the Hospital (i.e., medical staff, hospital department directors, external regulating agencies, etc.).

Demonstrates well-developed communication skills (both verbal and written).

Demonstrates ability to make effective presentations before groups of various sizes.

Demonstrates initiative, judgment, creativity and leadership abilities. Change management skills and the ability to network and influence. Have consultative, team building, and group facilitative skills, as well as strong project management skills.

Working Conditions

Works in an office environment.

Physical Demands

Requires the physical ability and stamina to perform the essential functions of the position.

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