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Employment Type:

Full time

Shift:

Description:

The purpose of the Manager of Quality and Safety is to manage at the local ministry level the quality and safety programming. The individual works collaboratively with the ministry’s executive team, leadership, providers, and colleagues to ensure high quality standards are cultivated in an environment of excellence, and outcomes are achieved. Leading and implementing strategies in quality and safety are a key component of the role.

The role has accountability for the following departments/functions: quality, patient safety improvement, culture of safety (Together Safe), and infection prevention. The manager collaborates with local leadership (President, Chief Operating Officer (COO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO)) to assure the highest levels of quality and safety.

The manager reports directly to the MercyOne RHM Director of Quality and Safety of Hospitals with an indirect reporting relationship to the local CMO (President in the absence of a CMO).

ESSENTIAL FUNCTIONS:

Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) mission, vision, core values, actions and promise in behaviors, practices, and decisions. Leads and effectively manages with oversight the areas of quality, patient safety (inclusive of the culture of safety (Together Safe) work) and infection prevention with high reliability principles and persistent mindfulness toward zero harm. Implements a quality performance improvement plan that meets Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) regulations and standards, in conjunction with the local executive team, leadership team, quality improvement committees (QICs), medical executive committee, and the board of trustees/directors and in alignment with the ministry’s strategies. Works collaboratively with leadership, providers, nursing staffs, and experts in developing and implementing quality and safety strategies that achieve high quality outcomes and safety for the patient population. Provides direct supervision of the quality, safety and infection prevention staff as assigned and assists in their development and competency. Provides leadership and/or participates in committees related to quality and safety inclusive of quality councils, board quality committees, and QICs. Identifies quality and safety areas of focus and works collaboratively to address findings proactively, that results in high quality and safe care. Leads continuous improvement activities to achieve and sustain excellence in CMS value-based programs, pay for performance programs of commercial carriers, and The Joint Commission in areas of quality measures and regulatory requirements. Leads and manages continuous improvement toward achieving excellent outcomes and recognition in regard to outside “rating” organizations, including (not all inclusive) CMS, Leapfrog, Healthgrades, Blue Distinction, etc. Actively collaborates with leaders of accreditation, risk management, customer experience, and performance excellence to provide identified and needed support for improvement. Develops quality excellence systems that integrate LEAN and other methodologies as appropriate that are data-driven and focused on quality improvement. Provides appropriate oversight, support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams. Works in collaboration with hospital leadership in improving the culture of safety that includes the concept of a “Just Culture” and “Together Safe”. Recommends and supports opportunities for improvement on cause analyses (apparent cause, root cause, common cause), Healthcare Failure Modes and Effects Analysis (HFMEA), and Patient Safety Organization (PSO) initiatives in collaboration with risk management. Oversees clinical data gathering/analytics ensuring accuracy of scorecards/dashboards for internal and external customers. Promotes an environment of shared leadership and decision-making. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior. Supports evidence-based practice, innovation and research. Participates in the clinical contracting process, consistent with legal and regulatory requirements. Contributes to the quality process in evaluating medical staff performance, inclusive of the focused and ongoing professional practice evaluation review process. Maintain awareness of and respond to issues in areas including the following:

+ Ethnic, cultural and diversity changes in the population

+ Political and social influences

+ Financial and economic issues

+ The aging of society

+ Ethical issues related to healthcare

SKILLS AND ABILITIES REQUIRED:

A thorough understanding of the health care environment and all applicable laws and regulations. In depth knowledge of high reliability organizations, quality excellence, change leadership, shared governance, matrix reporting, continuous improvement, operational, financial and productivity management. The ability to synthesize and interpret clinical, quality, and financial data. Proven time management skills with the ability to prioritize and organize work/projects in a fast-paced working environment so that all tasks are completed on time and accurately. Keeps current in area of expertise and assure that standards and practices reflect best practice within area of expertise. Maintains a professional, collaborative work environment so as to foster a positive public image for MercyOne. Possesses a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of MercyOne and Trinity Health. Provides a high level of customer responsiveness and serves as a role model to encourage a commitment to customer service. A strong service orientation is required. Excellent written and verbal communication skills with the ability to relate to people across all levels & diverse backgrounds; ability to handle interactions with discretion, tact & courtesy. Strong relationship builder, consultant and demonstrate the ability to deal successfully with inherent ambiguities and complexities. Demonstrates leadership and management abilities. Highly skilled in management technique, primarily in the areas of consensus and team building, colleague engagement, delegation, conflict management, etc. Flexible and demonstrates a great tolerance for change with ability to manage self and others through change. High aptitude for learning quickly, acting maturely and ethically. Ability to think creatively and analytically. Ability to demonstrate initiative. High degree of professionalism. Ability to handle confidential information in a sensitive manner. Demonstrates leadership skills and ability to implement processes and procedures.

MINIMUM QUALIFICATIONS:

Education:

+ Bachelor’s degree in nursing, health administration or related field required (master’s degree preferred).

+ Iowa licensure as a Registered Nurse.

Experience:

+ Requires a minimum of five (5) years of hospital experience in quality and/or safety, preferably in a progressive leadership role/manager level.

+ National certification in quality/safety required or to be acquire within 2 years of hire.

+ LEAN Six Sigma certification preferred.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran