The Quality Manager manages the facility quality and performance improvement (PI) programs, medical staff quality programs, including medical staff peer review and outcomes analysis. Promotes performance improvement, and staff education and development. The Quality Manager supervises quality review staff. ESSENTIAL JOB RESPONSIBILITIES Implementation and oversee quality activities within the facility, includes medical staff peer review.
Responsible for data analysis, collection and outcomes measures.
- Performs annual quality and PI program evaluation and reporting.
- Develops, revises, and implements quality and PI plan.
- Serves as a quality resource to all departments.
- Maintains and coordinates quality and PI report cards, dashboard, and other reporting mechanisms.
- Serves as member of selected facility and departmental PI committees, teams. Serves as Quality Facilitator/Leader of root cause analysis teams, etc.
- Analyzes and reports quality and PI indicators to the Quality Management Committee, Administration, and others as indicated.
- Ensures compliance of corporate, regulatory, and accreditation requirements for quality and performance improvement.
- Serve as representative to selected Partnership and other quality committees, initiatives, etc.
Completes administrative duties as needed.
- Analyzes and reports data from clinical outcomes systems such as CHOIS, TMF, Core Measures, THCIC, etc. as required or requested.
- Recommends action plans based on clinical data to the Medical Director, Medical Staff, Quality Management Committee, Administration, etc.
- Analyzes and reports satisfaction data and suggests action plans to administration and the customer service team.
- Provides oversight for Core Measures and other outcomes measures as determined by the Medical Staff, Administration, etc.
- Maintain quality and PI software and reporting systems to meet internal and external reporting requirements and surveys.
Comply with all hospital policies and procedures, safety requirements, and emergency preparedness requirements.
- Provides input in departmental goals, objectives, budget.
- Maintains confidentiality.
- Performs other duties as assigned.
- Complies with all hospital policies and procedures, safety requirements, and emergency preparedness requirements.
KNOWLEDGE, SKILLS AND ABILITIES
- Appropriately accesses secured rooms with medications storage containers in order to perform assigned job function, which does not include management of medications.
Understanding of quality principles, theories and tools. Data analysis and statistical background required. Ability to perform computerized analyses and use data management, word processing, and presentation software as required. Understanding of healthcare environment and strong project management skills are necessary for this position.
Understanding of clinical information, organizational behavior and group dynamics helpful. Ability to interact effectively with a variety of professions and persons. Effective written and verbal communication skills. Ability to perform detailed, concentrated work with limited supervision. Ability to identify issue and initiate improvements.
Must be able to demonstrate understanding of national patient safety initiatives by strict compliance to all safety protocols and procedures as required by both HCA and Round Rock Medical Center. Adheres to isolation policies and procedures. Utilizes universal precautions at all times. Works autonomously and with supervision. Interfaces with the public, physicians, staff, patients and administration and ancillary/support department representative. Maintains confidentiality of patient medical records. Regular and predictable attendance is required.Qualifications: EDUCATION AND EXPERIENCE Required:
Bachelor's Degree with preference given to Nursing, Quality Management or Healthcare Administration. Ten years' experience in healthcare or five years' experience in Quality. Preferred:
Master's degree in healthcare, nursing, quality or business. Advanced certification in Quality. LICENSES AND CERTIFICATES Preferred:
Licensed in the state of Texas as RN or hold eligible Compact license to practice as an RN in the state of Texas or
Certified Professional in Healthcare Quality REPORTING RELATIONSHIP Reports to:
Director of Quality Management. Positions supervised:
Quality review staff and others as assigned.
A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom