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Location
BLH Bronson LakeView Hospital, BSH Bronson South Haven

Title
Mgr Patient Safety & Quality

Responsible for planning, organizing and managing functions related to quality improvement and patient safety at Bronson. Works with the organization, PI Committees and ad hoc teams in developing quality improvement strategies, goals, targets and measurement plans to achieve best practice levels. Participates in the development and update of the annual Quality and Patient Safety Plans at Bronson. Medical Staff: Responsible for leading and supporting the Medical Staff structures with in the Bronson Healthcare system which includes credentialing (BLH only), peer review functions, and OPPE/FPPE. Also facilitates keeping the medical staff bylaws, rules, and policies current. Accreditation/Regulatory: Is responsible for the oversight of the Bronson's continuous readiness in assessing compliance in federal and state regulations, core measures, and patient safety. Provides assistance in the implementation of the value based purchasing initiatives and is responsible for the clinically related reporting requirements. Provides onsite coordination and leadership during CMS and Joint Commission surveys. Organizes and facilitates regularly scheduled audits and training with staff and leaders to implement "continuous readiness" strategies. Provides updates and education related to accreditation and changes in regulatory standards. Serves as the Joint Commission liaison and interacts with the account representative. Monitoring and Measurement: Develops and supports a system for regular and systematic collection, analysis, and reporting of quality data for public reporting and regulatory requirements; Recommends the Measures of Success submission at required Joint Commission time frames; Supports and directs data collection and research for key patient safety related clinical and operational activities. The Manager will coordinate the day-to- day departmental operations, as well as evaluate and oversee staff projects. The Manager acts as a role model, coach and mentor to staff, as well as a resource and contact person to staff and to others within and outside of the organization. The Manager ensures that all department standards are maintained as well as encourages a team environment and maintains positive customer service. Responsible to monitor and maintain approved department budget. Additional components of the role could include participation in: strategic plan tactics, regulatory compliance, data management/system management, policy and procedure development and review, and service line participation/support. Employees providing direct patient care must demonstrate competencies specific to the population served.

Bachelor's degree or an equivalent combination of education and experience, and 3-5 years of experience in clinical nursing in an acute care setting required
Master's degree preferred
Previous management experience preferred
Previous experience leading teams with improvement efforts preferred
Licensed RN in good standing with the State of Michigan required.
• Must work independently, be able to meet deadlines and demonstrate accountability for assignments
• Strong leadership, organization, and communication skills required
• Must be able to control confidentiality of sensitive information
• Must have the ability to use software relevant to the job (i.e. - Word, Excel, Access, PowerPoint, Visio, etc.).
• Must have the ability to organize and analyze data.
• Must be able to speak and write English fluently.
• Must be able to interpret regulatory standards and assess impact to the organization
Work which produces high levels of mental/visual fatigue, e.g., interactive and repetitive or small detailed work requiring alertness and concentration for sustained periods of time, the operation of and full attention to a personal computer or CRT between 40 and 70 percent of the time.
The job produces some physical demands. Typical of jobs that include regular walking, standing, stooping, bending, sitting, and some lifting of light weight objects.
• Oversees quality improvement and patient safety activities within the organization.
• Reviews current literature and provides recommendations for improvement activities
• Evaluates organizational data and understands variation and trends
• Analyzes and reports regarding regulatory readiness.
• Researches best practice and payer requirements and proposes / implements recommendations for change.
• Maintains department budget.
• Coordinates and analyzes progress reports from external agencies.
• Supports the Medical Staff credentialing (BLH only), peer review, and quality programs.
• Leads team through change process.
• Manages day-to-day operations of department
• Participates in evaluating performance of staff within the department

Shift
First Shift

Time Type
Full time

Scheduled Weekly Hours
40

Cost Center
1506 Patient Safety And Quality (BHG)