Acute Care Quality Manager

PURPOSE OF THIS POSITION

The purpose of this position is to provide acute quality and patient safety leadership for the organization.

This position provides leadership for inpatient and outpatient hospital quality and patient safety, analyzes and identifies safety trends, coordinates the patient safety committee, educates practitioners on the system-based causes for errors and injuries, consults with management and staff, and communicates evidence-based ideas regarding effective patient safety strategies. The Acute Care Quality Manager will assist the Director of Quality in gathering, storing, and retrieving data and information required for reporting to the Directors at Blanchard Valley Health System.

The Acute Care Quality Manager will assist in developing and managing events, activities and projects related to quality improvement. This position guides medical and patient care teams in achieving evidence-based care in varied inpatient and outpatient care settings, and ensures the integrity of internal and external quality metrics data. The Acute Care Quality Manager will maintain ongoing preparation for regulatory agencies.

• Duty 1: The Acute Care Quality Manager is responsible to oversee and administer the quality and performance improvement program and its functions for the hospitals’ inpatient and outpatients which include but are not limited to: patient safety, accreditation, infection prevention and peer review for the facility, Joint Commission accredited off site departments and additional areas as designated.
• Duty 2: Collaborates and acts as a resource to the system and medical staff in the analysis and submission of data, to ensure compliance with accreditation and regulatory agencies, CMS Conditions of Participation and payor requirements.
• Duty 3: Collaborates with the clinicians, administration, medical staff and department/services to assist in coordination, standardization, development of outcome measures and continuity of quality improvement initiatives.
• Duty 4: Facilitates the collection, aggregation and analysis of quality indicator data to provide a basis for internal and external benchmarking.
• Duty 5: Collaborates with the system leadership to develop quality and patient safety initiatives designed to improve patient outcomes and eliminate harm.
• Duty 6: Identifies areas of potential risk and participates in organization wide learning.
• Duty 7: Evaluates the effectiveness of current processes and leads team in continuous improvement projects.
• Duty 8: Serves as a resource for all internal and external customers for the Quality and Patient Safety program and its functions.
• Duty 9: Collaborates with Risk Management, Associate Safety and Patient advocate to investigate, follow-up and create action plans for Serious Safety and adverse events, and patient complaints and grievances.
• Duty 10: Oversees the development, implementation, and sustainment of the infection prevention initiatives and system improvements.
• Duty 11: Fosters a culture of transparency and non-punitive reporting to reduce associate and patient harm. Apply high reliability concepts through the application of systems thinking, safety science and the establishment of behavioral expectations. Complete patient safety culture assessment surveys as required.
• Duty 12: Reviews medical records accurately and timely to collect data for reporting of identified patient care indicators such as but not limited to:
  Surgical Case, Joint Commission and Medicare CORE measures, mortality, complications, readmissions, Anthem, Leap Frog, Ohio Department of Health, and Ohio Hospital Association.
• Duty 13: Leads and participates in safety investigations including Failure Mode Effective Analysis (FMEA) and Root Cause Analysis (RCA), including investigations for near-miss incidents, patient safety events to determine causes, implement countermeasures.
• Duty 14: All other duties as assigned.

• Bachelor’s degree in nursing or other allied health profession.
• Minimum of five years clinical experience.
• Certification in healthcare quality (CPHQ) through the National Association of Healthcare Quality or, attainment…