Quality Manager

POSITION/JOB SUMMARY

The Quality Manager is responsible for the leadership, development, implementation, and oversight of organization-wide Quality Assurance and Performance Improvement (QAPI/QAPI-PIPP) programs across the Critical Access Hospital, Rural Health Clinic, Surgical Services, Long-Term Care, and Assisted Living settings.

This position ensures compliance with all applicable federal and state regulations, including Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, Minnesota Department of Health (MDH) requirements, and other regulatory and accreditation standards.

The Quality Manager serves as an organizational consultant and subject matter expert in quality improvement, systems thinking, change management, and data analytics. The role leads moderate to complex performance improvement initiatives aligned with strategic priorities, utilizing Lean, Six Sigma, PDSA (Plan-Do-Study-Act), and A3 methodologies.

The Quality Manager promotes a culture of safety, regulatory readiness, and continuous performance improvement while demonstrating behaviors aligned with Johnson Memorial Health Services’ Core Values:
Together, Kindness, and Trust.

Days/

Hours:

M-F / 1.0 FTE
FLSA Status: Exempt

• Provide strategic oversight of organization-wide Quality Assurance and Performance Improvement (QAPI) programs in accordance with CMS Conditions of Participation for Critical Access Hospitals and Long-Term Care.
• Lead and coordinate Quality Improvement Performance Improvement (QIPI) and Performance Improvement Plan Projects (PIPP).
• Serve as quality consultant, facilitator, and project manager for moderate to complex performance improvement initiatives aligned with organizational strategic goals.
• Develop and support a standardized performance improvement framework across the organization.
• Utilize Lean, Six Sigma, PDSA, A3 thinking, and change management methodologies to drive measurable improvements.
• Establish appropriate performance metrics, monitoring plans, and control plans to ensure sustainability and hard wiring of improvements.
• Identify and remove barriers to project success or elevate appropriately to leadership.
• Mentor and coach leaders and teams in improvement science, project management, group facilitation, and systems thinking.
• Develop, implement, and monitor quality dashboards and performance metrics across all service lines.
• Ensure integration of quality initiatives across hospital, clinic, surgical services, long-term care, and assisted living.
• Monitor and report on:
  • Minnesota Community Measures
  • HCAHPS and CAHPS surveys
  • CMS Hospital Compare and Care Compare metrics
  • CMS 5-Star Quality Rating System
  • Minnesota Nursing Home Report Card measures
• Analyze trends and identify opportunities for improvement in clinical, operational, and patient experience outcomes.

• Ensure compliance with:
  • CMS Conditions of Participation (Critical Access Hospital and LTC)
  • Minnesota Department of Health regulations
  • HIPAA privacy and security standards
  • OSHA and workplace safety standards
• Serve as primary liaison during regulatory surveys, audits, and inspections.
• Lead preparation for state and federal surveys and coordinate corrective action plans.
• Ensure required quality metrics for accrediting and regulatory bodies are available to appropriate stakeholders.
• Oversee policy review and updates to maintain regulatory compliance.
• Monitor and respond to quality indicators related to infection prevention, medication safety, patient safety events, and risk management.

• Organize, facilitate, and maintain documentation for:
  • Professional Activities Committee (PAC) meetings
  • Quarterly Quality Assurance Department meetings
  • Monthly Care Center QAPI meetings
  • Quarterly Assisted Living Quality Assurance meetings
• Prepare and present quality reports to:
  • Management Team
  • Medical Staff
  • Senior Leadership Team
  • Board of Directors
• Ensure accurate documentation of committee minutes and regulatory reporting requirements.

• Gather, validate, and maintain statistical reports for hospital, clinic, surgical center, and senior…