Quality Manager

The Quality Manager will be responsible for the implementation and management of the Performance Improvement (PI) plan and maintaining compliance with Joint Commission and relevant State and Federal regulations related to quality monitoring and performance improvement. Oversees the day-to-day operations of the Quality Management staff.

ESSENTIAL KEY JOB RESPONSIBILITIES

Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement,

Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.

Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers. Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues. Supports implementation of regulatory initiatives.

Provides leadership to the Quality Management Department; hires, supervises, and monitors staff performance and productivity. Contributes to the budgeting process.

Educates and trains staff and physicians in quality improvement including the aggregation and analysis, action planning and reporting of performance data.

Works in collaboration with hospital leadership and medical staff to meet goals established in the Performance Improvement plan.

Required Education & Experience:

Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.

• Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization’s Quality Improvement Program.
• Minimum of two (2) years of clinical, patient care experience or equivalent.
• Experience with quality improvement methodology and data analysis
• Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.

Required License & Certification:

• Current state license in a clinical field; 5 (five) years’ experience in Quality Management can be used in lieu of state license.
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

Required Minimum Knowledge, Skills, Training & Abililties:

• Knowledge and expertise in specific performance improvement/CQI methodologies (e.g. Six Sigma, LEAN).
• Current knowledge of data reporting and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; Joint Commission, etc.).
• Understands the importance of striving toward a zero defect goal and ability to establish methods and metrics that deliver targeted standards for products and services
• Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/reward contributions; defines clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary
• Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations
• Supervisory and/or management experience
• Ability to work well under pressure and respond to changing needs and complex environments
• Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization

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Baylor St. Luke’s Medical Center is an internationally recognized leader in research and clinical excellence that has given rise to breakthroughs in cardiovascular care, neuroscience, oncology, transplantation, and more. Our team’s efforts have led to the creation of many research programs and initiatives to develop advanced treatments found nowhere else in the world. In our commitment to advancing standards in an ever-evolving healthcare environment, our new McNair Campus is designed around the human experience—modeled on evidence-based practices for the safety of patients, visitors, staff, and physicians. The 27.5-acre campus represents the future of healthcare through a transformative alliance focused on leading-edge patient care, research, and education. Our strong alliance with Texas Heart® Institute and Baylor College of Medicine allows us to bring our patients a powerful network of care unlike any other. Our collaboration is focused on increasing access to care through a growing network of leading specialists and revolutionizing healthcare to save lives and improve the health of the communities we serve.