What are the responsibilities and job description for the MANAGER QUALITY & ACCREDITATION position at Oneida Health?
Position Summary
The Manager for Quality and Accreditation is responsible for development, implementation, and evaluation of quality assurance and quality improvement projects/processes in order to continually monitor and improve patient care across the system. This position works closely with the System Director of Quality, Department Heads, Chief Nursing Officer, Chief Medical Officer and Compliance Officer to ensure all accreditation and reporting requirements are met. This position involves significant interdepartmental collaboration and knowledge of electronic health records and other data systems. The employee interprets regulatory and accreditation standards, reports on data obtained related to these standards, and conducts educational programs for hospital employees and members of the medical staff. The Manager reports to the System Director of Quality, Safety and Clinical Risk.
Key Responsibilities
Qualifications
EDUCATION: Bachelor’s degree (required); Master’s degree (preferred)
EXPERIENCE: Minimum of three (3) years of relevant experience in quality, patient safety, accreditation, or performance improvement. Knowledge/ experience in Lean Six Sigma, PDSA or other performance improvement methods. Current regulatory, accreditation experience.
LICENSES & CERTIFICATION: Unencumbered Registered Nurse (RN) license in State of New York (required); Certification in specialty (preferred).
Required Skills, Knowledge & Abilities
The Manager for Quality and Accreditation is responsible for development, implementation, and evaluation of quality assurance and quality improvement projects/processes in order to continually monitor and improve patient care across the system. This position works closely with the System Director of Quality, Department Heads, Chief Nursing Officer, Chief Medical Officer and Compliance Officer to ensure all accreditation and reporting requirements are met. This position involves significant interdepartmental collaboration and knowledge of electronic health records and other data systems. The employee interprets regulatory and accreditation standards, reports on data obtained related to these standards, and conducts educational programs for hospital employees and members of the medical staff. The Manager reports to the System Director of Quality, Safety and Clinical Risk.
Key Responsibilities
- Act as liaison to other departments for the purpose of identifying and resolving quality improvement activities.
- Facilitate inter- and intradepartmental communication about quality improvement.
- Assist the Director to develop an annual quality assurance plan and prepare methods for continued assessment or evaluation on the effectiveness of current quality assurance activities.
- Prepare and distribute reports on results of quality assurance activities which will include recommendations to resolve identified problems.
- Maintain continuity in the analysis of activities, documentation of information and data, follow-up activities to improve the quality of care and completion of reporting functions.
- Attend medical staff committee and other departmental and committee meetings affecting quality assurance problems and activities affecting the monitoring and resolution of identified problems.
- Follow up on all activities performed in compliance with quality assurance plans and make recommendations or perform corrective action.
- Act as resource on regulatory requirements and on quality improvement processes.
- Assist management in identifying opportunities and interventions for improvement based on the needs of internal and external stakeholders.
- Perform monthly random chart audits.
- Remain abreast of and ensure compliance with risk-related state and federal regulatory standards.
- Collaborate with key stakeholders to develop and implement a Quality Strategic Plan, including opportunities for growth, new technologies, delivery system opportunities, and operational improvements across the care continuum.
- Engage and implement effective team building, trust, development, creative problem-solving and conflict resolution processes.
- In collaboration with the Director, implement and manage all organizational safety directives and goals.
- Role model and lead to promote interdisciplinary collaboration and shared accountability while continually improving the experience of patients, providers, and staff.
- Effectively present data/ recommendations at the department and organizational level.
- Articulate and present data, information, and ideas in a clear and concise manner.
- Communicate with medical staff, department leaders, senior leaders, and board members to maintain coordination across the system.
- Ensure integration of ethical standards and core values into everyday work activities.
- MANAGEMENT OF RESOURCES
- Support Director with budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control.
- EDUCATION/OUTREACH
- Actively participate in development of policies, procedures, education and best practice.
- Foster strong working relationships with all levels of the organization to facility effective communication and to connect to staff’s daily priorities to the organization’s strategic goals.
- Maintain membership in professional organizations to develop knowledge and resources through networking, continuing education, and participation in national, regional, and/or local activities.
- RESEARCH/BEST PRACTICE
- Evaluate current research for applicability within units/ programs of care.
- Ensure results of quality assurance studies are used to identify and design process improvement projects.
- Monitor and report key performance indicators across the system.
- Remain current of new trends and best practices and incorporate into practices and programs.
- Develop and implement clinical outcome measures for quality improvement, cost and complication reduction, and implementation of evidence-based practices.
Qualifications
EDUCATION: Bachelor’s degree (required); Master’s degree (preferred)
EXPERIENCE: Minimum of three (3) years of relevant experience in quality, patient safety, accreditation, or performance improvement. Knowledge/ experience in Lean Six Sigma, PDSA or other performance improvement methods. Current regulatory, accreditation experience.
LICENSES & CERTIFICATION: Unencumbered Registered Nurse (RN) license in State of New York (required); Certification in specialty (preferred).
Required Skills, Knowledge & Abilities
- Managerial skills necessary to plan, organize, and direct operational activities
- Strong organizational and negotiation skills that are conceptual as well as practical
- Demonstrated interpersonal skills necessary to interact with all levels of hospital personnel and external parties
- Strong clinical knowledge of best clinical practices
- Comfort with an interdisciplinary culture of collaboration, particularly partnering with key stakeholders to achieve goals.
- A passion for excellence, which elevated the abilities and competencies of the various patient care providers
- Excellent verbal and written communication skills with meticulous attention to detail