Position Purpose: The Quality Improvement (QI) Manager for Specialty Services leads the development, facilitation, and coordination of quality improvement programs (clinical, operational, and service line) for the Schwab Rehabilitation Program and other specialty services, resulting in high reliability, improved patient care, operations, and patient experience consistent with the mission and values of Sinai Health System. This position collaborates with hospital and medical Staff to achieve quality goals through initiatives relating to improved operations, processes, and procedures and to elevate clinical excellence. Additionally, this role facilitates activities associated with rehabilitation specific metrics applicable to CMS regulations, CARF and industry standard quality programming. This includes applicable abstraction management and oversight of associated databases and systems. This position assists with the completion of the medical staff peer review process.
Key Job Activities:- Identifies best practice and leads interdisciplinary teams to implement improvement to achieve high reliability and zero harm.
- Proactively stays informed and current on professional rehabilitation and other specialty services practice and regulatory issues and seeks methods necessary to address new standards of care, guidelines or preferred practice patterns.
- Facilitates, leads, and collaborates on rehabilitation and other program-specific Quality Performance Improvement projects to align strategic priorities, interventions, and standard work to harmonize system-wide approaches where appropriate.
- Partners with departments and service lines to identify best practice to close gaps and utilize a data-driven approach to improvement.
- Leads data-driven performance improvement projects utilizing QI skills and tools to determine priorities for improvement, clinical or business process knowledge to know where efficiencies and workflows can be improved and rapid improvement cycles.
- Creates action plans and communicates status to improve key system-wide metrics and track implementation, effectiveness, and compliance to assure accountability.
- Co-leads assigned clinical department quality meetings, including the Schwab quality meeting, by planning meeting agenda, clinical data presentation, identification of areas of improvement based on current metrics and best practice, and preparation of meeting minutes in collaboration with the department chairperson and clinical analytics. Responsible for understanding data analysis, core measures or applied metrics and communicating quality information to individuals and groups.
- Assists with oversight of tracking and resolution of event reporting in partnership with the leadership team.
- Serves as a role model for quality excellence, performance improvement, and culture of safety.
- Demonstrates current knowledge of QI principals, tools and concepts and a commitment to continued learning as identified by System goals and department-specific needs.
- Trains leadership, caregivers, providers, and rehabilitation residents in the use of quality and performance improvement methodology and their respective responsibilities in carrying out the program; including oversight of required annual quality competency validation. Oversight includes supporting the rehabilitation residents with quality improvement projects.
- Manages medical staff Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE), and peer review program and assures consistent application across sites and disciplines. Assists with development of such processes as needed.
- Supports the organization's drive to achieve and maintain top decile performance as measured by, CMS, and other publicly reported methodologies.
- Reviews assigned quality cases such as mortality reviews, acute care transfers, patient safety indicators, hospital acquired conditions, and other quality indicators. May assign physician review cases, analyze and distill data from applicable reviews. Completes reports in a timely manner.
- Develops and presents quality improvement presentations and dashboards for system, hospital and medical staff committees and assists in their preparation for board meeting presentations.
- Utilizes and prepares performance improvement tools such as flowcharts and FMEAs, and interprets results using control charts and other data analysis tools.
- Demonstrates an ability to adapt to emergent requirements for quality and patient safety initiatives.
- Facilitate daily site patient safety huddle. Actively participate in system safety huddles representing Schwab Rehabilitation program.
- Plans and provides for orientation of new staff and onboarding process.
- Designs educational experiences for caregivers on new Quality practices for Schwab Rehabilitation Hospital. Plans educational events for the nursing department.
- Maintains documents and records in compliance with departmental, organizational and external agency requirements, i.e., in-service attendance, competency records/ skills checklists, quality boards, etc.
- Seeks out and champions research, appreciative inquiry and research projects for all departments at SRH. Provides site leadership as Schwab representative on IRB. Oversees compliance with required quality university education.
- Performs other duties as assigned.
Education and Work Experience: - A bachelor's degree in a health-related field required, nursing and a master's degree preferred.
- 4-5 years of related healthcare experience required. Clinical experience in nursing, leadership and/or quality improvement experience preferred.
- Experience using Lean, Six Sigma, or other performance improvement methodology.
- Experience with peer review, mortality review, and chart abstraction for publicly reported quality measures.
- Clinical experience preferred.
