The Manager, Quality and Patient Safety supports the facility's quality, patient safety, and compliance programs by coordinating performance improvement activities, monitoring key process and outcome measures, and facilitating communication across clinical and operational teams. This position analyzes data, conducts audits, and assists in investigations to ensure timely follow-up on safety events and continuous improvement in care delivery. The Manager, Quality and Patient Safety provides education and guidance to staff, supports required committees and reporting functions, and helps maintain survey readiness and regulatory compliance. The position also assists with onboarding processes, ensures completion of required documentation and training, and contributes to quality and service excellence initiatives that promote safe, high-quality patient care throughout the facility. Essential Functions: 1 Collaborate with multi-disciplinary teams to identify problems, develop solutions, and support performance improvement initiatives. 2 Maintain and analyze databases on process and outcome metrics; communicate findings related to quality and patient safety to facility leadership. 3 Conduct audits and other data collection methods to evaluate progress on outcome and process measures. 4 Respond to safety-related issues in a timely manner and support the investigation and follow-up of incidents, including Root Cause Analyses. 5 Act as a resource for staff on quality, patient safety, and compliance matters, providing education as needed. 6 Monitor staff completion of required training and compliance elements. 7 Conduct rounds and observe practice/process changes to identify quality and safety issues and ensure adherence to standards. 8 Support Quality Council, Medical Executive Committee, and Governing Board functions, including preparation of agendas, minutes, and quarterly reports. 9 Communicate effectively with nursing leadership and other staff to ensure hand-off of pertinent issues for follow-up and resolution. 10 Ensure accurate and timely completion of unit-level documentation, including staffing sheets, environmental rounds, and concurrent medical record audits. 11 Assist with orientation of new and agency staff to facility policies, procedures, and standards, ensuring completion of required orientation documentation. 12 Support regulatory compliance and survey readiness, including participation in surveys, Plan of Correction development, and mandated reporting to state and accrediting bodies. 13 Complete assigned quality and safety initiatives, including Service Excellence projects, Camera Checks/Reviews, and Environment of Care reports, ensuring compliance with facility protocols. 14 Perform other duties as assigned. Requirements Education / Experience: Bachelor's Degree, master's degree Preferred Minimum of three (3) years of experience in an acute care hospital setting. Acute inpatient psychiatric setting preferred. Experience in teaching, clinical program development and database management preferred. Skills / Abilities: Proficient in office and computer applications, including Microsoft Word, Excel, E-fax, and other software used for data collection and reporting. Strong knowledge of CMS Conditions of Participation, Joint Commission Standards, and state licensing requirements. Ability to collect, organize, and analyze data related to quality, patient safety, and compliance. Skilled in conducting audits, environmental rounds, and other data collection methods to assess adherence to policies and standards. Ability to identify quality and safety issues and follow up appropriately, including supporting Root Cause Analyses. Effective verbal and written communication skills for reporting findings, providing education, and coordinating with staff and leadership. Ability to monitor completion of required training and compliance elements for staff. Detail-oriented with strong organizational skills to manage multiple operational tasks, documentation, and reporting deadlines. Ability to work collaboratively with multi-disciplinary teams to support process improvement and safety initiatives. Commitment to maintaining confidentiality and integrity when handling sensitive patient and staff information. Work Environment: Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.