The Quality Manager oversees and manages all aspects of quality assurance and quality improvement across all departments including our acute care hospital, skilled nursing facility, school health program, transportation services, and community health centers. This role involves the development, implementation, and monitoring of quality improvement initiatives to ensure compliance with regulatory standards and to optimize patient and resident care outcomes. The Quality Manager collaborates with administrative, clinical, and medical leadership across all healthcare settings to foster a culture of safety, measure quality of care, and identify opportunities for performance improvement. This position serves as the organization's liaison with accrediting bodies and ensures readiness for external audits, inspections, and regulatory compliance.

Essential Functions:

Quality Improvement:

Lead and execute quality improvement projects and initiatives across in assigned department. Analyze data to identify areas for improvement and implement evidence-based strategies to enhance patient/resident outcomes. Monitor the effectiveness of implemented quality initiatives and adjust strategies as necessary. Conduct comprehensive reviews of departmental audits and systematically analyze and monitor emerging trends and areas for improvement.

Regulatory Compliance:

Ensure practices comply with local, state, and federal regulations, including those set by The Joint Commission and other accrediting bodies. Coordinate accreditation activities, including leading compliance teams and committees. Maintain readiness for unannounced agency visits and participate in various regulatory agency surveys. Oversee responses to external audits, inspections, and surveys, ensuring timely and effective resolution.

Leadership and Collaboration:

Provide strategic oversight of patient safety activities, including root cause analyses and proactive approaches to mitigating risk. Collaborate with Risk Management to integrate quality and risk management practices and participate in incident investigations and corrective action planning. Lead quality committees and coordinate with multidisciplinary teams on monitoring, reporting, and improving clinical care, operations, and compliance with regulatory requirements. Stay current on industry trends, best practices, and emerging technologies in quality assurance and healthcare delivery.

Data Management and Reporting:

Collaborate with IT to create quality improvement dashboards and analyze relevant trends. Prepare and present reports on quality performance and improvement initiatives to leadership and stakeholders. Perform regular audits of patient and resident records to ensure compliance with policies, procedures, and regulatory bodies. Manage requests for data and support the development of comprehensive quality management reports. Establish processes for ongoing monitoring of data metrics and process for addressing improvements. Monitor and report quality measures to regulatory bodies within established deadlines.

Education and Training:

Develop and provide Quality and Patient Safety education organization-wide. Ensure efficiency in peer review processes and produce meaningful reports to evaluate effectiveness. Identify and communicate educational topics based on improvement opportunities identified during audits.