Healthcare Quality & Safety Performance Improvement Manager (40 Hours, Days)

Schedule: 40 Hours, Days, Full-Time, Benefit Eligible

Position Summary:

The Quality Analytics and Performance Improvement Manager will support the implementation and monitoring of programs and activities designed to ensure that Boston Medical Center - South incorporates methods to improve the safe administration of care into all clinical processes while developing a culture that perceives safety to be of paramount importance.

The Quality Analytics and Performance Improvement Manager will be expected to collaborate and provide guidance to hospital staff daily to identify and remove barriers to ensure an error-free clinical and non-clinical setting consistent with defined regulating and accreditation standards (Joint Commission, Medicare Conditions of Participation, Departments of Public Health, Mental Health, etc.). The Manager role will serve as the hospital's lead to ensure a continuous state of readiness and meeting all Joint Commission, CMS, and DPH standards by standardizing processes for evaluation of compliance of standards, identifying opportunities for improvement, implementing changes to hospital operations to meet expected regulatory readiness, and measuring effectiveness of interventions with standardized tracer and audit activities.

Responsibilities:

• The Quality Analytics and Performance Improvement Manager participates in the development and implementation of hospital and medical staff performance improvement initiatives. Participates as the Hospital's representative, data collector, and reporter in collaborative quality improvement projects both internally and externally.
• Identifies cases where established criteria are met or not met and reports to appropriate people about results in a timely manner. This Manager role is responsible for preparing reports, data, and projects to external and internal regulatory entities.
• Assist the Quality and Patient Safety Team with strategic performance improvement initiatives throughout the hospital. Reports quality measure results to medical staff, assisting them with interpretation of results. Develops action plans for all noncompliant standards with measurement of effectiveness.
• Performs data collection in a timely manner and meets regulatory agencies deadlines for reporting data.
• Actively participates in and/or leads committees and meetings that are focused on quality, safety, and performance improvement measurements at the direction of the Sr. Director of Quality and Safety.
• Coordinates the regulatory compliance program to meet the standards identified by the TJC, DPH, and CMS. Support project structure to ensure all staff are involved in regulatory readiness on a daily basis. Is supported by the hospital leadership in assuring this process is hospital-wide. Is knowledgeable of all standards specific to the Joint Commission, CMS, DPH, OSHA, FDA, etc. Collects and administers necessary tools and reports to monitor organization's activities specific to regulatory readiness (tracer rounds, chart audit, etc.).
• Identifies and implements educational materials and agendas for all organization stakeholders to ensure continuous regulatory readiness.
• In coordination with the Sr. Director of Quality and Safety and the Risk Manager, manages all survey activities from arrival and coordination of survey activities to exit exercises, inclusive of successful completion of any action plan associated with the survey process to ensure ongoing accreditation.
• Ensures the organization is always appraised of all standard changes/updates and implements plans to ensure compliance with changes in a timely manner. As it relates to standards specific to patient safety, it provides oversight in the implementation of improved systems for tracking, evaluating, and communicating patterns in patient safety for the hospital.
• Works closely with the system's clinical leadership, to implement pilot programs designed to eliminate the following: preventable mortality, adverse drug events, falls, pressure ulcers, surgical complications, nosocomial infections, and other patient safety goals as defined by the Joint Commission.
• Additional duties assigned.

Required Knowledge & Skills:

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  Education: Bachelor's Degree in a healthcare related field with lean methodology and/or statistical analysis.
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  Experience:
  
  
  • 2-4 years' experience in a leadership position with experience in performance improvement and project management.
  • Graduate degree in healthcare/related field or equivalent in training/experience required preferred.
  
  
  
  
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  Certification/Licensure:
  
  
  • Current RN or other healthcare license preferred.
  • Lean, Six Sigma, CPHQ preferred.
  
  
  
  
• Highly motivational communication skills are accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
• Performs analytical and decision-making functions with minimal supervision.
• Demonstrates an understanding of relative Hospital and departmental policies and procedures.
• Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.

Equal Opportunity Employer/Disabled/Veterans