Quality Manager

Final date to receive applications: 07/17/2025

Job Summary:
The Quality Manager is responsible for leading and overseeing all aspects of quality management and performance improvement initiatives at Oak Leaf Surgical. This position plays a crucial role in ensuring the delivery of high-quality patient care, compliance with regulatory standards, and continuous improvement of processes and outcomes.

Essential Job Functions

Strategic Functions:

• Develop, implement, and manage a comprehensive quality management program tailored to the unique needs of Oak Leaf Surgical.

• Collaborate with departmental leaders to establish and maintain quality indicators, benchmarks, and performance metrics.

• Facilitate performance improvement initiatives to enhance patient outcomes, patient safety, and overall efficiency.

• Implement benchmarking activities to compare the hospital’s performance with industry standards.

Operational Functions:

• Monitor and evaluate clinical and non-clinical processes to identify opportunities for improvement.

• Lead efforts to prepare for and participate in accreditation surveys, certification surveys, and regulatory audits.

• Conduct root cause analyses, high priority reviews, and proactive risk assessments.

• Build relationships with providers to ensure patient safety and regulatory compliance are followed.

• Implement corrective action plans to address identified issues.

• Utilize data analytics to assess and report on key performance indicators, trends, and areas for improvement.

• Develop and present regular reports to hospital leadership, medical staff, and relevant committees.

• Lead the education department to design and deliver training programs related to quality improvement, patient safety, and regulatory compliance.

• Lead risk management to identify, assess, and mitigate potential risks to patient safety and quality of care.

• Participate in the development and implementation of risk reduction strategies.

• Foster collaboration and communication among various departments, medical staff, and other stakeholders to achieve quality improvement goals.

• Chair and participate in Performance Improvement and Safety Committee.

• Chair and participate in Administrative Policy Committee.

• Chair and participate in Health Equity Committee.

• Participate in the following committees:
Emergency Management, Total Joint Certification, Educational Council, Antibiotic Stewardship, Utilization Management, and Water Management committees.

• Oversee Infection Control and Employee Health program to ensure compliance with regulatory bodies.

• Serves as a member of the Internal Review Board and the Medical Executive Committee

• Develops and implements solutions to meet the ongoing documentation requirements of the hospital while maintaining patient safety.

• Stay informed about industry best practices and trends in quality management for surgical hospitals.

• Completes annual review of assigned policies.

Leadership Functions:

• Direct, administer and manage the operations of assigned functions.

• Assign tasks and review work of direct reports.

• Monitor direct reports adherence to Hospital protocols and procedures.

• Provide performance management directive including annual evaluations, coaching, development and corrective action.

• Engage in staff development through education and training.

• Ensure direct reports have adequate equipment and resources to carry out high quality patient care.

• Ability to perform as administrator on-call rotation.

• Ability to attend meetings outside of normal business hours as needed.

Other duties as assigned.

Knowledge

Skills and Abilities:

• Ability to take control of situations and dictate subordinate activities in a responsible manner.

• Ability to instruct and train in policies and procedures.

• Ability to prepare performance evaluations and make recommendations regarding unsatisfactory employees.

• Ability to assign work, add or delete, plan work and establish priorities.

• Ability to comprehend, retain and apply the requirements of any governmental or regulatory body.

• Ability to exhibit strong communication, presentation and listening skills to ensure facility-wide collaboration and…