Manager - Quality and Risk Management

JOB SUMMARY: The Manager of Quality and Risk Management has the responsibility for overseeing the coordination, implementation and follow-up on activities related to these areas of service. This includes the Quality Program, Risk Management Program and meeting organization regulatory requirements, and works in partnership with the WNJ administrative and medical staff leadership and provides leadership in the development of a culture of safety and the measurement of the quality of care identifying opportunities and strategies for performance improvement (PI). Assumes a leadership role in accreditation and licensure activities. Works collaboratively with administration, medical staff, department managers and staff in performing duties. Investigates potential problem areas under direction of Quality Improvement Committee, Medical Staff Chairpersons and Administration. Oversees preparing of reports, summaries and statistical data including the hospital-wide Performance Improvement Summaries by the Quality and Clinical Review Coordinators. Serves as a liaison between outside agencies and the hospital in matters concerning Performance Improvement in conjunction with other clinical leaders. Conducts in-services or other education programs on Performance Improvement. This position will report to the CEO.

EDUCATION, EXPERIENCE, TRAINING
1. Bachelor’s degree in nursing or other clinical degree preferred.
2. Master’s degree in nursing, hospital administration, public health, or related field preferred.
3. RN license or licensed in related field in healthcare preferred.
4. One of the following industry recognized quality certifications required upon hire or within 12 months of employment:
a. Certified Professional in Healthcare Quality (CPHQ)
b. Certified Professional in Patient Safety (CPPS)
c. Certified Professional in Healthcare Risk Management (CPHRM)
d. Healthcare Accreditation Certification Professional (HACP)
e. Other industry specific quality related certification
5. Minimum of five years’ experience in an inpatient health care setting.
6. Minimum of five years’ progressive management/supervisory experience in healthcare performance improvement.
7. Proficiency in word processing, spreadsheets and databases.

ESSENTIAL FUNCTIONS
1. Initiates and oversees the development of a comprehensive safety/quality/performance improvement/IC program inclusive of the analysis and trending of data related to initiatives.
2. Provides oversight for patient safety and quality committees with accountability for distribution of organizational communication vertically and horizontally within WNJ as appropriate.
3. Identifies and defines performance improvement processes and communicates to the staff. Supervises Performance Improvement Coordinator efforts with departments and Medical Staffing in the area of Performance Improvement.
4. Provides direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and Joint Commission standards that are evidence-based.
5. Manages and assists with patient safety activities including root cause analysis, failure mode effects analysis and Sentinel Event Alerts in regards to the facilitation of processes, planning, implementation and evaluation of effectiveness of process changes.
6. In conjunction with the medical staff, coordinate safety/quality/performance/IC initiatives.
7. In collaboration with clinical staff and services chiefs, participates in the monitoring, reporting and improvement activities related to clinical guidelines, health care quality/safety initiatives, accreditation and regulatory requirements.
8. Fosters and maintains collaborative relationships within WNJ and with external agencies related to quality/performances initiatives.
9. Regularly communicates PI and quality/safety/IC activities to leadership and staff.
10. Supervises and directs Infection Control Nurse, Performance Improvement and Quality Review Coordinators, Data Entry Coordinator and Patient Experience Coordinator.
11. Performs staff performance evaluation establishing a development plan for each employee.
12. Maintains regular attendance.
13. All other duties as assigned or required.