PURPOSE OF THIS POSITION

The purpose of this position is to provide acute quality and patient safety leadership for the organization.

This position provides leadership for inpatient and outpatient hospital quality and patient safety, analyzes and identifies safety trends, coordinates the patient safety committee, educates practitioners on the system-based causes for errors and injuries, consults with management and staff, and communicates evidence-based ideas regarding effective patient safety strategies. The Acute Care Quality Manager will assist the Director of Quality in gathering, storing, and retrieving data and information required for reporting to the Directors at Blanchard Valley Health System. The Acute Care Quality Manager will assist in developing and managing events, activities and projects related to quality improvement. This position guides medical and patient care teams in achieving evidence-based care in varied inpatient and outpatient care settings,and ensures the integrity of internal and external quality metrics data. The Acute Care Quality Manager will maintain ongoing preparation for regulatory agencies.

JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment.

DELEGATION OF AUTHORITY

You are delegated the authority, responsibility, and accountability necessary to carry out your assigned duties.

REQUIREMENTS

• Bachelor’s degree in nursing or other allied health profession.

• Minimum of five years clinical experience.

• Certification in healthcare quality (CPHQ) through the National Association of Healthcare Quality or, attainment within 3 years after employment

• Proficiency in Microsoft programs including word, excel, and PowerPoint.

• Effective written and oral communication, public speaking and interpersonal skills

• Ability to multi-task with attention to detail

• Positive service-oriented interpersonal and communication (written and verbal) skills required.

• A valid driver's license is required (if you do not have a valid Ohio driver’s license you must obtain one within 30 days of your residency in the state). You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.

• Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his/her assigned unit/department. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status. Must be able to interpret the appropriate information needed to identify each patient’s requirements relative to their age-specific needs and to provide the care needed as described in the area’s policies and procedures.

• This position is classified “at risk” for possible occupational exposure to blood borne pathogens (HBV, HIV, etc.)

PREFERRED QUALIFICATIONS :

• Lean and/or Six Sigma

• Joint Commission regulations

• Risk management principles including Failure Mode Effective Analysis (FMEA) and Root Cause Analysis (RCA)

• Qualitative and quantitative data collection, analysis, and presentation

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent bending, squatting, kneeling, and twisting. The associate must be able to sit for three hours, walk for one hour and stand for two hours per day. The associate must be able to lift 20 pounds. The individual must have excellent eye/hand coordination to operate the machines. This position requires corrected vision and hearing in the normal range. This position requires excellent verbal skills to communicate with applicants, employees and management. The associate must be able to operate a motor vehicle.

JOB DUTIES/RESPONSIBILITIES

During the performance process, please assess the level at which the staff member achieves the job accountabilities. Please use the 'Comments' section to document specific examples of performance issues, staff member's strengths and/or shortcomings, areas of suggested performance improvement and other comments as appropriate to further the staff member's growth and development.

Duty 1: The Acute Care Quality Manager is responsible to oversee and administer the quality and performance improvement program and its functions for the hospitals’ inpatient and outpatients which include but are not limited to: patient safety, accreditation, infection prevention and peer review for the facility, Joint Commission accredited off site departments and additional areas as designated.

 Duty 2: Collaborates and acts as a resource to the system and medical staff in the analysis and submission of data, to ensure compliance with accreditation and regulatory agencies, CMS Conditions of Participation and payor requirements.

Duty 3: Collaborates with the clinicians, administration, medical staff and department/services to assist in coordination, standardization, development of outcome measures and continuity of quality improvement initiatives.

Duty 4: Facilitates the collection, aggregation and analysis of quality indicator data to provide a basis for internal and external benchmarking.

Duty 5: Collaborates with the system leadership to develop quality and patient safety initiatives designed to improve patient outcomes and eliminate harm .

Duty 6: Identifies areas of potential risk and participates in organization wide learning.

Duty 7: Evaluates the effectiveness of current processes and leads team in continuous improvement projects.

Duty 8: Serves as a resource for all internal and external customers for the Quality and Patient Safety program and its functions .

Duty 9: Collaborates with Risk Management, Associate Safety and Patient advocate to investigate, follow-up and create action plans for Serious Safety and adverse events, and patient complaints and grievances.

Duty 11: Oversees the development, implementation, and sustainment of the infection prevention initiatives and system improvements.

Duty 12: Fosters a culture of transparency and non-punitive reporting to reduce associate and patient harm. Apply high reliability concepts through the application of systems thinking, safety science and the establishment of behavioral expectations. Complete patient safety culture assessment surveys as required.

Duty 13: Reviews medical records accurately and timely to collect data for reporting of identified patient care indicators such as but not limited to: Surgical Case, Joint Commission and Medicare CORE measures, mortality, complications, readmissions, Anthem, LeapFrog, Ohio Department of Health, and Ohio Hospital Association.

Duty 14: Leads and participates in safety investigations including Failure Mode Effective Analysis (FMEA) and Root Cause Analysis (RCA), including investigations for near-miss incidents, patient safety events to determine causes, implement countermeasures.

Duty 15: All other duties as assigned.