Summary:
The Manager of Quality and Patient Safety provides leadership in ongoing performance improvement and quality activities with demonstrated outcome improvement, enhancing Bon Secours Charity service delivery. The Manager of Quality and Patient Safety works under the direction of the Vice President, Quality and Safety, independently, to assure completion of critical to quality work which includes audits, rounds, chart abstraction, tracers, and investigation of events. As a highly visible leader, The Manager seeks out opportunities for improvement and applies improvement methodology and tactics to assist organizational leaders in achieving highly reliable practices and processes.
Responsibilities:- Performs required CMS, NYDOH, TJC and other chart abstraction.
- Reviews, and as appropriate, investigates actual or potential safety events.
- Performs chart review for quality or peer review.
- In collaboration with Medical Staff Leadership assures timely completion of peer review activities.
- Provides leadership for internal quality, peer review and mortality and morbidity meetings.
- Participates in tracer activity, clinical and/or environmental rounds when appropriate to maintain a state of continuous service readiness for regulatory surveys.
- Works collaboratively with leadership across the organization in the following roles: identification and management of key performance indicators, audit workflows, action planning, and investigation.
- Provides statistical analysis in the healthcare setting, and renders technical assistance to departmental leaders in the preparation and analysis of data.
- Works collaboratively with other components of care delivery (i.e. Nursing, Ancillary/Support Services, and Medical Staff Office) to ensure that a coordinated and comprehensive quality program is implemented, continually assessed, and standards are being met and/or exceeded.
- Performs tracers and environmental rounding.
- Oversees the completion of required action plans and ensures ongoing assessment and compliance.
- Maintains confidentiality of all quality/performance improvement documents, data, and meeting discussions.
- Provides leadership during a Sentinel Event Process and Root Cause Analysis.
- Assist in the development, compliance, and monitoring of quality initiatives related to The Joint Commission, NYSDOH, Disease Initiatives, CMS, Qhip, HANYS/EQIC and other regulatory agencies.
- Manages assigned projects within the facility in an organized, professional, and timely manner, including developing work plans, ongoing evaluation of progress, and reporting the results and reasons for variances to appropriate leadership.
- Prepares analyses and reports, to communicate progress, recommendations etc. to Bon Secours Executive Leadership and the Board of Directors.
- Manages the corrective action and performance improvement of significant safety events and survey activity.
- Performs other duties as assigned.
Qualifications/Requirements:Experience: Minimum of 5 years of experience in nursing. Experience in healthcare setting with extensive knowledge of healthcare regulatory requirements and quality improvement initiatives preferred.
Must possess broad understanding of healthcare delivery operations. Proficiency with Microsoft Office Products (word, PowerPoint, excel) Excellent written/ oral communication, time management, and organization skills is required.
Education: Bachelor's degree in Nursing required.
Licenses / Certifications: current NYS nursing license required. CPHQ preferred.
Special Requirements: This position provides oversight of Quality, Patient Safety and Regulatory issues at Good Samaritan Hospital. Occasional travel will be required to Bon Secours Community Hospital and St. Anthony's Community Hospital as business needs dictate.
