What are the responsibilities and job description for the Manager, Quality & Performance Improvement- University Hospital position at University of South Alabama Health System?
Overview
USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.
Responsibilities
The Manager, Quality and Performance Improvement (QI/PI) is responsible for overseeing and managing the quality assurance and performance improvement functions within the hospital. This position ensures that programs and services meet the highest standards, aligning with the organization’s mission to deliver exceptional patient care. The manager is responsible for the development, implementation, and monitoring of QI/PI initiatives, compliance with regulatory standards, and continuous process improvements. This position demands a highly organized, motivated, and forward-thinking individual who thrives in a fast-paced, detail-oriented environment. The Manager, Quality and Performance Improvement will demonstrate a passion for improving patient care, fostering a culture of safety, and engaging staff and leadership in the pursuit of excellence in healthcare delivery.
o Abides by and enforces all compliance requirements and hospital policies, including confidentiality and safety standards.
o Demonstrates ethical behavior consistent with the organization’s values and ensures quality standards are upheld.
o Advocates for the engagement of patients and families in quality improvement activities.
o Leads or participates in various quality and performance improvement committees.
o Oversees the quality assurance and performance improvement programs to ensure optimal patient care and regulatory compliance.
o Utilizes performance improvement tools to assist teams in identifying, evaluating, and implementing improvements in care processes.
o Maintains accurate, complete & confidential information utilized in the hospital Quality Assurance and Performance Improvement Program.
o Coordinates initiatives through collaboration with the patient safety division that align with regulatory standards and organizational priorities, such as reducing patient harm and improving patient safety.
o Participates in Root Cause Analysis (RCA), Failure Mode and Effect Analysis (FMEA), and performance improvement projects based on sentinel events or near misses.
o Participates in and/or coordinates a proactive risk assessment/failure mode effect analysis project every 18 months at a minimum.
o Oversees quality peer review coordinator’s essential job function priorities.
Analyzes complex data and uses statistical methods to identify improvement opportunities and ensure compliance with quality standards.
o Prepares and monitors reports on performance improvement metrics, including core quality measures and electronic clinical quality measures (eCQMs).
o Prepares annual reports for hospital leadership, such as the Quality and Safety Dashboard and contract evaluation reports.
o Updates the Quality Improvement Plan according to accreditation agency requirements.
o Responsible for meeting Quality Measure data elements compliance according to TJC and CMS specification guidelines including: abstraction of Core Quality Measure guidelines by QM concurrent review staff and abstracting QM staff, recommending inpatient /outpatient measure process and documentation improvements to ensure optimum outcome results and, meeting validation compliance.
o Coordinates and oversees the annual medical study submission to the state Quality Improvement Organization (QIO).
o Assists the Clinical Compliance & Regulatory Director in the preparation process for accreditation and regulatory surveys, when needed.
o Assesses hospital compliance with accreditation standards and regulatory agencies related to performance improvement standards.
o Monitors and evaluates results of surveys as it related to PI opportunities and other care monitoring results.
o Builds and fosters strong working relationships with all levels of hospital staff, including physicians, nurses, and administrative teams.
o Communicates effectively with patients, families, and staff to ensure smooth collaboration on quality initiatives.
o Demonstrates effective customer relations and addresses concerns with professionalism and empathy.
o Promotes professional growth through education programs, workshops, and conferences related to quality and performance improvement.
o Trains hospital personnel on QI/PI practices and tools, including documentation, data collection, and improvement techniques.
o Responsible for performing personnel functions for the department, e.g., recruitment, hiring, orientation, supervising, evaluations, counseling, disciplinary actions, payroll and education.
o Prepares and monitors the department’s annual budget.
o Ensures that QI/PI staff adhere to hospital policies and regulatory requirements, while encouraging a positive and supportive work environment.
o Provides mentorship and coaching to foster continuous improvement and staff development.
o Supports initiatives in line with National Patient Safety Goals, including harm reduction and the promotion of evidence-based practices.
o Ensures patient and family engagement strategies are integrated into quality improvement projects.
o Encourages a culture of safety, advocating for constructive feedback and addressing system improvement opportunities.
In-depth knowledge of accreditation standards, regulatory requirements, and performance improvement methodologies.
· Strong data analysis, problem-solving, and project management skills.
· Requires minimal supervision to safely perform essential functions
· Possesses superior time management skills with the ability to multi-task and prioritize, establish timelines and meet deadlines
· Excellent communication and interpersonal skills with the ability to work collaboratively with multidisciplinary teams.
· Ability to lift and move equipment/supplies with proper body mechanics.
Completes all mandatory training, hospital and department requirements.
· Adheres to infection control and safety standards, including the proper maintenance of work areas and equipment. Reports broken or malfunctioning equipment.
Regular and prompt attendance as required by the department and hospital schedules.
· Works the assigned schedule. Ability to work overtime and be on-call as needed.
· Performs other related duties as assigned by the leadership.
Qualifications
Bachelor's degree in healthcare administration, nursing, or related field from an accredited institution as approved and accepted by the University of South Alabama and three years of quality management or performance improvement experience in a healthcare setting. Project management experience is required. Master's degree is preferred. Supervisory experience is preferred. Certification in Quality Management (CPHQ) or Performance Improvement (CQI, Six Sigma, Lean) is highly preferred.
