Manager, Quality - CW
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Mobile, AL 36607
Manager, Quality – CW
Quality Management CW, AL
USA Health Children’s & Women’s
USA Health helps people lead longer, better lives through its excellence in education, research and medical care. With more than 3,600 employees, USA’s health network includes University Hospital, Children’s & Women’s Hospital, Mitchell Cancer Institute, Physicians Group, and the College of Medicine. Each year, our team of 180 physicians, 240 residents and fellows, 70 advanced practitioners and 800 nurses handle some 185,000 clinic visits and 350,000 outpatient procedures. USA Health delivers 2,800 babies a year, more than any other regional hospital, and treats patients through some 60,000 emergency room visits annually.
In addition to advanced and innovative patient care offered at University hospitals and clinics, USA’s medical education programs provide first-class training experiences for the next generation of physicians and scientists. USA Health delivers excellence in care while improving the quality of life for residents across the Gulf Coast.
USA Health is managed by the USA HealthCare Management, LLC.
Oversees quality assurance and performance improvement functions to ensure programs and services are implemented at the highest standards and the patient receives the highest level of care; monitors and maintains institutional compliance with governmental/regulatory rules and regulations for quality assurance/performance improvement; acts as a resource and educates hospital personnel about quality assurance/performance improvement; participates in various committees of the hospital and/or Health System; participates in and/or coordinates Root Cause Analysis teams according to the Sentinel Event Reporting Policy as needed; participates in and/or coordinates Failure Mode and Effect Analysis teams as required under the Joint Commission (TJC), as needed; collaborates with the multidisciplinary healthcare team regarding development and implementation of the Quality program; participates in the hospital employee orientation; determines topics for review, including, but not limited to: high risk, high volume or problem-solving activities, and facilitating the performance improvement framework for all projects; provides education to the multidisciplinary department/service to accomplish the goals and techniques of Quality Assurance/Performance Improvement (QAPI); assists the Accreditation Manager in the preparation process for accreditation and regulatory surveys, when needed; assesses hospital compliance with accreditation standards and regulatory agencies related to performance improvement standards; monitors and evaluates results of surveys as it relates to PI opportunities and other care monitoring results; submits the annual medical study to the state Quality Improvement Organization (QIO); performs personnel functions for the department, to include recruiting, hiring, orientation, assigning duties and approving time off; prepares and monitors annual budget; prepares reports, attends and presents committee meeting materials; responsible for developing, implementing and updating hospital and department policies and procedures in a collaborative and interdepartmental process according to the Joint Commission and CMS standards; updates Quality Improvement Plan according to accreditation agency requirements; prepares the Quality Department annual reports, contract evaluations report, Quality and Safety dashboard reports, etc.; responsible for meeting Quality Measure data elements compliance according to TJC and CMS specification guidelines including: abstraction of Core 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; completes the validation process for electronic clinical quality measures (eCQMs) and meaningful use quality indicators according to specifications; responsible for the American Heart Association " get with the guideline" measures for Heart Failure and Stroke; responsible for Stroke Joint Commission Certification and the submission of performance improvement data submissions; participates in the Hospital Staff and Medical Staff orientation and annual updates on performance improvements, as needed; responsible for coordinating and leading multidisciplinary teams to improve documentation and quality care; supports Quality Department staff functions of medical staff peer review, hospital PI, Certification and Quality measures such as concurrent and retrospective Core Measure abstraction; requires minimal supervision to safely perform essential functions; utilizes proper body mechanics when moving equipment/supplies that are necessary to perform essential functions; maintains and operates equipment and reports broken of malfunctioning equipment; communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone; responds to texts and emails in a timely manner; documents personnel actions appropriately; accepts and completes all duties positively and without conflict; cooperates, helps others and improves the performance of the department; completes all mandatory department, educational and hospital requirements; utilizes cost effective practices in performing all aspects of the job; maintains orderliness and cleanliness of work areas, equipment and supply areas; adheres to current Infection Control and Safety Standards; abides by and enforces all compliance requirements and polices and performs these responsibilities in an ethical manner consistent with the organization’s values; adheres to hospital policies including confidentiality; enhances professional growth and development through participation in education programs; regular and prompt attendance; ability to work schedule as defined and additional hours as required; related duties as required.
Bachelor’s degree in a healthcare related field form an accredited institution as approved and accepted by the University of South Alabama, three years of professional quality management or directly related experience in a hospital setting, and current licensure with the state of Alabama in clinical field of study. Experience in Quality Assurance Performance Improvement is preferred. A master’s degree is preferred. Supervisory experience is preferred. CPHQ certification is preferred.
Working Days and Hours
Monday – Friday
8:00 a.m. – 4:30 p.m.