Quality & Patient Safety Manager

Assumes the daily department responsibility for quality improvement and patient safety. Assists the Quality Officer with education and consultations to the CEO, Board of Directors, medical staff, and department heads and hospital staff. Assists with leading the hospital accreditation survey process. Maintains hospital compliance with regulations and standards using tracer methodology and centralized tracking.

The primary goal is to assure the hospital is in full compliance with all accreditation and licensure standards at all times. An additional component of the job involves the management of the Risk Management and Patient Safety Program designed to identify, prevent and minimize risk.

Works collaboratively with the system insurance carrier, ensuring effective measures are developed, implemented and maintained to maximize efforts to decrease or eliminate the patient, visitor, staff and organizational risk of adverse occurrences. Works collaboratively with the Infection Control and the Environment of Care Committee on recognizing, eliminating and controlling health hazard risks in the workplace.

Key Responsibilities And Deliverables

• Prepares directives, guidelines, information on various components of quality management and patient safety for dissemination throughout the Hospital.
• Develops and maintains repository of clinical criteria, articles and other resource material for dissemination throughout the Hospital.
• Develops and maintains a quality and outcomes management information system.
• Leads the performance improvement program.
• Directs the collection, measurement and presentation of data required for monitoring quality and patient safety indicators
• Assists with leading the hospital accreditation survey process. Reviews accreditation and regulatory agencies survey findings and develops and manages action plans to address non-compliance.
• Facilitates tracer activity as leader of the tracer team.
• Assists the Quality Officer in developing and managing the education and technical expertise in quality improvement and patient safety of the hospital staff, medical staff and Board of Directors.
• Performs ongoing reviews of regulations, healthcare law and informs hospital leaders and staff of changes.
• Directs the review of all occurrence reports submitted for completeness of documentation and accuracy. Reviews, analyses, aggregates and trends all occurrence reports.
• Leads the team in any Root Cause analysis necessary and reports findings to the appropriate people
• Facilitates the reporting any potential claims to the insurance carrier in a timely manner.
• Provides ongoing monitoring and evaluation of the effectiveness of the hospital performance improvement, patient safety and risk management programs. This includes an evaluation of the previous year plan and assuring the plan for the next year is approved by the appropriate committees.
• Oversees the medication, supplies, and equipment recall process.
• Participates in orientation and the ongoing education and training of hospital staff.
• Works collaboratively with the Infection Control Program as well as the Environment of Care Committee to identify and correct unsafe conditions and work practices.
• Keeps and open line of communication with legal counsel to facilitate any medical records and legal requests.
• Any and all other duties as assigned.
  
  
  

Education: Bachelor's degree in Nursing

Certification/License: RN license in the State of Louisiana.

Experience: Minimum of 5 years of management or supervisory experience in healthcare; Quality management and patient safety program experience preferred.