Quality Improvement Manager (Full Time):> Print Application
Position Summary:
Under the administrative leadership of the CMO, the incumbent will manage and oversee all quality improvement operations at MHSI. The Quality Improvement Manager will provide leadership and support to the staff assigned to the organization’s Health Care Disparities Collaboratives. The QI Manager will assist the organization in its preparation for JCAHO and any other accreditation processes elected by the corporation. In conjunction with the Director of Operations, the QI Manager will revise the organization’s Patient and Employee Safety Programs. The QI Manager will develop and implement a Risk Management Plan for the corporation.
Duties and Responsibilities
Continuous Quality Improvement and Accreditation Preparedness
1.Under the leadership of the CMO, facilitates the development, implementation and annual review of the MHSI Continuous Quality Improvement Program Plan (CQIP).
2.Participates on and/or facilitate meetings and activities of the CQIP Core and Sub-Committees.
3.Coordinates and monitors the activities and proceedings of the CQIP Sub-Committees, including the preparation of minutes and reports.
4.Identifies, assesses and monitors quality improvement opportunities related to the provision of ambulatory health care services.
5.Provides recommendations for problem resolution and appropriate follow-up of quality related issues, problems and concerns.
6.Oversees and/or conducts periodic medical and/or electronic health record reviews/audits, and facilitate the completion of periodic peer review audits and other related activities.
Quality Improvement Manager
7.Publishes and/or communicates audit results to the appropriate parties in a timely manner, using a standardized format.
8.Conducts periodic training sessions with the MHSI Staff and Board of Directors on relevant quality improvement topics and subject matter.
9.Collects and summarizes performance improvement data and report findings and outcomes quarterly to the CQI Program Core Committee and MHSI Senior Management Team.
10.Collaborates with and represents MHSI with external agencies and organizations involved in quality and performance improvement programs and initiatives.
11.Facilitates the development of policies and procedures related to accreditation and related reassessment activities.
Health Disparities Collaboratives (HDCs)
12.Reviews monthly RSR/DQIP reports quarterly to assess the organization’s progress with the Depression and Diabetes HDCs (e.g., patient outcome measures, self-management goals and objectives).
13.Performs periodic medical record audits to measure compliance of MHSI Provider Staff to clinical practice guidelines for diabetes mellitus and depression.
14.Plans and conducts quarterly in-service and continuing education opportunities for the MHSI Collaborative Teams and other Clinical Staff.
15.Prepares and presents biannual progress reports to the Senior Management Team and CQI Program Core Committee in conjunction with the HDC Team Leaders.
Risk Management
16.Develops and implements the organization’s risk management plan in conjunction with the Director of Operations.
17.Develops and implements policies and procedures for the identification, collection and analysis of risk related data and information.
18.Educates and trains MHSI Staff and leadership on the organization’s risk management plan.
19.Assists, facilitates and advises MHSI departments and organizational units on appropriate risk management activities and strategies.
20.Collects, evaluates and maintains data concerning patient and employee injuries and related claims, including worker’s compensation claims.
21.Performs internal investigations and root cause analyses to identify patterns and trends with the goal to prevent liability to the corporation, and identifies and implements corrective action plans to avoid reoccurrences.
22.Prepares and presents biannual progress reports to the Senior Management Team and CQI Program Core Committee in conjunction with the Director of Operations.
Patient and Employee Safety Programming
23.Receives and investigates reports of accidents and other adverse safety events to determine their causes and to make recommendations for improving internal safety procedures and controls.
24.Monitors the safety investigations/inquiries of Department Managers and Supervisors involving patients and employees to assure that timely investigations are completed and proper procedure is followed.
25.Develops and maintains a system of internal reporting for safety related events and to provide timely reports and/or summaries of safety events on a quarterly basis to the President/CEO and the Senior Management Team.
26.Identifies appropriate training topics, programs and resources for MHSI Staff.
27.Performs the annual safety audit and generates a report of findings and recommendations from the audit in conjunction with the Director of Operations.
28.Assists the Director of Operations with the planning, execution and reporting of fire, safety, and emergency preparedness drills.
29.Performs other duties as assigned and required.
Education, Training and Experience
Baccalaureate prepared Registered Nurse, licensed in the State of Wisconsin. Advanced education (e.g., Master Degree in nursing, health care or health information management) with three to five years of experience in health quality management, quality assurance and/or quality improvement highly desired. A minimum of five years work experience in a culturally diverse, frenetic ambulatory or community based health care setting. Certified Professional in Healthcare Quality (CPHQ) or similar certification in quality assurance or health quality management strongly preferred.
Knowledge, Abilities and Skills
Knowledge of current local, state and federal laws and regulations and accreditation standards related to the delivery of ambulatory health care, safety and risk management.
Ability to manage and supervise subordinates.
Ability to communicate effectively and persuasively, both orally and in writing.
Ability to organize, develop, implement, monitor and evaluate professional work plan goals and performance objectives.
Computer literacy with proficiency and expertise in Microsoft Office, including software applications for WORD, EXCEL, and ACCESS.
Ability to develop, implement and manage individual projects and those of the CQI Program Sub-Committees and Adhoc Teams.
Ability to perform effectively in a culturally diverse work environment.
Excellent interpersonal skills and ability to work effectively with others in the workplace.
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