Manager of Quality and Safety
Listed on 2026-08-03
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Quality Assurance - QA/QC
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Management
Description
The purpose of the Manager of Quality and Safety is to manage at the local ministry level the quality and safety programming. The individual works collaboratively with the ministry’s executive team, leadership, providers, and colleagues to ensure high quality standards are cultivated in an environment of excellence, and outcomes are achieved. Leading and implementing strategies in quality and safety are a key component of the role.
Employment Type
Full time
Shift
Day Shift
Description
The purpose of the Manager of Quality and Safety is to manage at the local ministry level the quality and safety programming. The individual works collaboratively with the ministry’s executive team, leadership, providers, and colleagues to ensure high quality standards are cultivated in an environment of excellence, and outcomes are achieved. Leading and implementing strategies in quality and safety are a key component of the role.
The role has accountability for the following departments/functions: quality, patient safety improvement, culture of safety (Together Safe), and infection prevention. The manager collaborates with local leadership (President, Chief Operating Officer (COO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO)) to assure the highest levels of quality and safety.
The manager reports directly to the Mercy One RHM Director of Quality and Safety of Hospitals with an indirect reporting relationship to the local CMO (President in the absence of a CMO).
- Knows, understands, incorporates, and demonstrates the Mercy One (Trinity Health) mission, vision, core values, actions and promise in behaviors, practices, and decisions.
- Leads and effectively manages with oversight the areas of quality, patient safety (inclusive of the culture of safety (Together Safe) work) and infection prevention with high reliability principles and persistent mindfulness toward zero harm.
- Implements a quality performance improvement plan that meets Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) regulations and standards, in conjunction with the local executive team, leadership team, quality improvement committees (QICs), medical executive committee, and the board of trustees/directors and in alignment with the ministry’s strategies.
- Works collaboratively with leadership, providers, nursing staffs, and experts in developing and implementing quality and safety strategies that achieve high quality outcomes and safety for the patient population.
- Provides direct supervision of the quality, safety and infection prevention staff as assigned and assists in their development and competency.
- Provides leadership and/or participates in committees related to quality and safety inclusive of quality councils, board quality committees, and QICs. Identifies quality and safety areas of focus and works collaboratively to address findings proactively, that results in high quality and safe care.
- Leads continuous improvement activities to achieve and sustain excellence in CMS value-based programs, pay for performance programs of commercial carriers, and The Joint Commission in areas of quality measures and regulatory requirements.
- Leads and manages continuous improvement toward achieving excellent outcomes and recognition in regard to outside “rating” organizations, including (not all inclusive) CMS, Leapfrog, Health grades, Blue Distinction, etc. Actively collaborates with leaders of accreditation, risk management, customer experience, and performance excellence to provide identified and needed support for improvement.
- Develops quality excellence systems that integrate LEAN and other methodologies as appropriate that are data-driven and focused on quality improvement.
- Provides appropriate oversight, support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams.
- Works in collaboration with hospital leadership in improving the culture of safety that includes the concept of a “Just Culture” and “Together Safe”. Recommends and supports opportunities for improvement on cause analyses (apparent cause, root cause, common…
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