Overview
Summary: Facilitates and coordinates hospital wide quality management programs to ensure compliance with Joint Commission, State, Federal and other regulatory requirements. Facilitates compliance with core measures and all process improvement activities.
Essential Functions:
1. Analyze complex situations to identify opportunities for improvement using data driven decision making
2. Assist departments in the development, implementation, and monitoring of performance and outcomes measurement
3. Prioritizes projects based on the organization’s strategic quality goals
4. Develops strategies to implement projects
5. Manage projects, including department resource allocation and team development
6. Uses analytical skills for improving patient safety and enhancing the quality of patient care
7. Develop action plans as needed to demonstrate compliance with State, Federal and Joint Commission regulations; including follow up with SRA findings and others as necessary
8. Facilitate, prep, minutes for PSCQ Committee
9. Oversight of Power BI Dashboard and PI audits
10. Facilitate maintaining standards compliance for regulatory readiness, oversee AMP use and documentation of FSA, including tracers
11. Keep current knowledge of National Patient Safety Goals, involving hospital departments and conducting quality audits
12. Partner with the education team and others for annual Joint Commission /Regulatory Fair
13. Collect, interpret, and present deep dives in harms and mortality data
14. Assist with nursing performance improvement projects and initiatives, eg. restraints, code data, etc.
15. Maintain various regulatory logs, eg. death within 24 hours of restraint, etc.
16. Partner with Plant Operations for completing Environment of Care Rounds
17. Inpatient core measure concurrent review/ intervention and abstraction: sepsis, etc.
18. Serve on various committees – Nursing IP Sub-committee, Infection Prevention, Code Blue, etc.
19. Lead quality, patient safety orientation for new employees
20. Facilitate PI teams
21. Act as a resource for Quality-driven PolicyStat policies, ensuring compliance with development and approval
22. Builds relationships throughout the hospital in order to improve patient safety, providing staff education, and being an available resource for quality objectives
*_Required Education_*_: _
Bachelor’s degree is required
*_Required License:_*
License in clinical area required
*_Required Certification: _*
CPPS and/or CPHQ preferred
**Job:** **Quality*
**Organization:** **Central Carolina Hospital*
**Title:** *Manager – Quality*
**Location:** *NC-Sanford*
**Requisition ID:** *7468-3989*
