SUMMARY:
The Manager of Quality is responsible for the operational management and supervision of Quality Coordinators and the Infection Preventionist, ensuring effective execution of Quality Assurance (QA), Performance Improvement (PI), and Infection Control (IC) activities at the facility level. This position oversees daily departmental operations, supports staff
development, ensures accurate data collection and reporting, and facilitates implementation of quality initiatives across departments.
ESSENTIAL FUNCTIONS:
• Directly supervises Quality Coordinators and the Infection Preventionist, providing guidance, oversight, and performance management.
• Assigns and monitors workload to ensure completion of audits, surveillance, data abstraction, and reporting functions.
• Oversees execution of the facility QA, PI, and IC programs to ensure operational effectiveness.
• Ensures infection surveillance activities are conducted consistently and findings are communicated appropriately.
• Reviews audit results and performance data with staff and ensures follow-up actions are implemented and tracked to completion.
• Participates in root cause analyses and ensures assigned corrective actions are carried out and monitored.
• Ensures timely and accurate collection, validation, and submission of required quality and infection control data as directed by the Director of Quality.
• Supports survey readiness activities by coordinating documentation, audit findings, and action plans.
• Implements policies and procedures related to QA, PI, and IC and monitors departmental adherence.
• Escalates identified regulatory or compliance risks to the Director of Quality for further action.
• Collects, analyzes, trends, and reports quality indicators, infection control metrics, and performance improvement data.
• Develops and maintains tracking tools, dashboards, and action plans to support measurable improvement.
• Presents findings and recommendations to leadership, committees, MEC, and Board as assigned.
• Conducts routine and focused audits to validate compliance with standards of care and organizational policy.
• Develops and delivers education programs related to quality improvement, infection prevention, and regulatory compliance.
• Ensures staff completion of required QA, PI, and IC education and competency validation.
• Provides real-time coaching to staff to reinforce best practices and regulatory expectations.
• Oversees and tracks employee health requirements, including screenings, immunizations, and required documentation.
• Ensures employee health records are complete, accurate, and maintained in accordance with regulatory standards.
• Partners with department leaders and clinical staff to implement performance improvement initiatives and corrective action plans.
• Serves as a resource for quality and infection control standards across departments.
• Educates patients and families regarding infection prevention and quality-related practices as appropriate.
• Maintains accurate, timely, and compliant documentation in accordance with organizational policy and privacy regulations.
• Participates in assigned committees and meetings related to quality, safety, and performance improvement.
• Perform other related tasks as needed.
KNOWLEDGE, SKILLS, AND ABILITIES:
• Knowledge of healthcare regulations, accreditation standards, and infection control requirements.
• Strong organizational, analytical, and problem-solving skills.
• Ability to collect, analyze, and report quality and performance data.
• Effective verbal, written, and interpersonal communication skills.
• Ability to manage competing priorities in a fast-paced healthcare environment.
• Demonstrated attention to detail and commitment to accuracy.
• Ability to work independently while collaborating effectively with leadership and staff.
• Proficiency with electronic health records, quality reporting systems, and Microsoft Office applications.
• Ability to maintain professionalism, composure, and sound judgment in high-stress situations.
• Documented training and demonstrated competency in infection prevention and performance improvement methodologies required.
EDUCATION AND EXPERIENCE:
• Five (5) years of experience in healthcare quality in an Acute Care Hospital setting
• Registered Nurse or Licensed Vocational Nurse in the State of Texas
• Basic Life Support (BLS) certified
BENEFITS:
3 Medical Plans
2 Dental Plans
1 Vision Plan
Employee Assistance Program
Short and Long-Term Disability Insurance
Basic and Voluntary Life with AD&D Plan
401(k) with a 2-year vesting
PTO + Holidays
Compensation to be determined by the education, experience, knowledge, skills, and abilities of the applicant, internal equity, and alignment with market data.
