Summary

The Quality Manager position provides dedicated quality management leadership across the combined musculoskeletal and neuroscience service lines. This role drives clinical quality improvement, regulatory readiness, and accreditation/certification maintenance for both specialties, serving as the primary quality liaison between frontline clinical teams, service line leadership, and hospital=wide quality/patient safety functions. The position requires strong knowledge of orthopedic and neuroscience clinical standards, as well as expertise navigating disease-specific certification programs (e.g., Joint Commission Advanced Certification for Total Hip/Knee, Spine Surgery, Stroke Certification, etc.).

The Manager uses the Code of Ethics for Nurses with Interpretive Statements to guide leadership and practice.

The Manager attains knowledge and competence reflective of current nursing practice; promotes innovation and futuristic thinking by incorporating evidence-based practice and research findings.

Responsibilities

(30%)* Quality Management: In collaboration with the MyMichigan Health Service Line Director and Chief(s), assume responsibility for the clinical and quality performance management of the MyMichigan Health Orthopedic and Neuroscience Programs, as defined by any MyMichigan Health care setting in which orthopedic or neuroscience patients are being treated; Participates in the development, implementation, monitoring and revision of standards, policies, procedures, and protocols for patient care; analyze and report outcomes to relevant committees.

(30%)* Accreditation and Certification Management: Facilitate performance improvement activities discussions and activities to resolve program related issues; Lead neuroscience and orthopedic certification compliance and activities at all MyMichigan Health subsidiaries and ensure that program adheres to applicable certification requirements and guidelines; Monitor certification compliance and activities at MyMichigan Health subsidiaries; Be knowledgeable of most current applicable certification requirements and care standards; Monitor continuum of care of stroke and total joint patients to ensure effective throughput.

(20%) * Data & Registry Management: In collaboration with Service Line Leadership and Medical Director, oversee appropriate data entry and abstraction for reporting (MSSIC, MARCQI, AJRR, Get With The Guidelines - Stroke). Validate data accuracy and completeness prior to submission. Use registry benchmarking data to identify performance improvement opportunities. Organize and participate in multi-disciplinary committees and coordinate regular case reviews.

(10%) * Education and Clinical Resource Activities: Act as clinical and quality resource/educator for staff across both service lines; Participates in community screening/education events;

(10%) * Leadership and Collaboration: Mentor and educate staff on quality principles, documentation standards, and regulatory requirements; Collaborate with Infection Prevention, Risk Management, Information Technology and Health Information Management on cross-functional quality initiatives; Lead data abstraction teams; Maintain relationship with referring organizations and oversee patient care feedback; Liaison with teleneuro/telestroke providers and partners;

OTHER DUTIES AND RESPONSIBILITIES:

Coordinate, participate in, and/or facilitate education surrounding the Stroke, Spine, and Total Joint care to each hospital in the system.

Monitor changes in accreditation standards and update policies, order sets, and workflows accordingly.

Serve as primary point of contact during on-site accreditation/certification surveys.

Lead multidisciplinary team in collaboration with Medical Director(s).

Maintain in depth knowledge of guidelines in both Neuroscience and Orthopedics. Build on established relationships with EMS agencies and transfer hospitals in the region.

Review and evaluate data monitoring and handling to determine consistency of data collected from various sources.

Recommend changes and modifications to systems as required to ensure timeliness, accuracy, and efficiency.

Prepare reports and analyses setting forth progress, roadblocks, appropriate recommendations for project success, and/or conclusions as requested.

Respond to inquiries about the project according to established policies and procedures.

Recommend various actions including, but not limited to, project performance appraisals, technical assistance needed, and budget revisions.

Travel to subsidiaries to conduct invited site visits and provide educational assistance.

Oversee MSSIC and MARCQI data abstraction and reporting activities.

Provide education and support materials regarding MSSIC/MARCQI guidelines and quality metrics.

Oversee the Total Joint program and nurse navigators.

Review and implement standard procedures/protocols for total joint care throughout the system.

Certifications and Licensures

BLS - Basic Life Support

Required Equivalent Experience - Within 3 months of hire or transfer.

Required Education

Education: Bachelors Degree

Comments: Master's degree in clinical or health related field preferred at the time of hire or transfer to position.

Other Information

EXPERIENCE, TRAINING AND SKILLS:

Knowledge of nursing practices and procedures as normally acquired through 4 years' experience working in a Medical Center or similar setting with direct experience caring for both Orthopedic and Neuro patients.

Knowledge of nursing leadership as normally acquired through working 2 years' in a Medical Center or similar setting with involvement in supervision, charge nurse, project implementation, quality improvement, professional development program, shared governance leadership role, or equivalent.

Knowledge of project management/continuous improvement methodology.

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.

PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:

Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.

Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.

Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.

Overall vision and hearing are necessary with or without assisted device(s).

Frequently required to sit/stand/walk for long periods of time.

May require frequent postural changes such as stooping, kneeling or crouching.

Some exposure to blood borne pathogens and other potentially infectious material.

Must follow MyMichigan Health bloodborne pathogen and TB testing as required.

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.

Physical Demand Level: Sedentary. Must be able to occasionally (0?33% of the workday) lift or carry 0?10 lbs.