A Clinical Quality Manager ensures that the quality of the work in a clinical environment is consistent and meets government and industry standards as well as customer expectations. Verifies compliance with health and safety regulations. Coordinates all activities related to quality assurance and monitoring and revises existing processes in order to increase efficiency.
The Director of Quality Management and Risk is responsible for developing the Quality Assurance and Performance Improvement (QAPI) annual plan and insuring the successful implementation of the plan. Ensures that data is collected from all appropriate sources, the data is examined and the results are shared with all departments and the Board. Oversees the process to evaluate and resolve medical and non-medical grievances by participants, their family members or representatives. The Director acts as the compliance manager and monitors the hospital services to improve the quality of patient care and assures that services are provided in a safe and efficient manner. Responsible for coordination of the quality program within the hospital, as well as links to MPRO, state and national endeavors. This entails quality control, quality performance, quality assurance, quality improvement and quality planning/education and performance improvement. Direction for all quality improvement, daily planning/education and Performance improvement. Direction for all quality activities will evolve from this position. This position may involve supervision of other facility staff involvement with facility administrative staff, medical staff, and board members. Responsible for monitoring hospital credentialing process to assure that medical providers credentialed in compliance with Behavioral Center of Michigan's staff and current State and Federal guidelines.
REPORTS TO
. Chief Executive Officer
QUALIFICATIONS
Masters degree preferred; Bachelors Degree required 5-10 years experience in behavioral health field At least 3 years previous experience in managing Risk/QAPI in an inpatient psychiatric setting Expert knowledge of statistical analysis and reporting practices pertinent to quality improvement and program evaluation Expert knowledge of common statistical programs, spreadsheet and database management, Key performance Indicators and QAPI Dashboard. Ability to communicate in English, both verbally and in writing. Strong leadership skills Licenses/Certifications Valid RN License- State of Michigan Certified Professional in Healthcare Quality (CPHQ), strongly preferred. AGE(s)
OF PATIENTS SERVED
Adult Population:
Age 18 and up
DUTIES AND RESPONSIBILITIES
Work with all departments within the facility to assist with development of departmental quality goals, goal measurement tools, quality initiatives and methodologies. Serves as a resource on quality indicators, peer review, medival and nursing "best practices", national quality initiative and any other quality factor as they might be developed. Stay abreast of National, State, MPRO and local focuses on quality factors. Able to create key performance Indicator reports and design QAPI dashboard for each department. Working knowledge of patient rights, always focusing on patient's needs and providing quality care. Maintains strict confidentiality in regard to patient names, diagnoses, treatment and all other information which falls in category of "personal health information" (PHI). Demonstrates the ability to initiate, accept and implement change. Demonstrates communication skills, verbal and written, in providing analysis, reports. Supports the concept of continuous quality performance by participating as needed to (re)design programs or systems and/or solve problems with a goal of improving. Demonstrates effective documentation skills to insure accuracy and completeness of the facility quality programs.
Essential Functions:
Demonstrates knowledge of quality improvement, safety, rick management concepts and activities and maintains a broad clinical base of current patient care practices, maintaining strict adherence to confidentiality in all phases. Demonstrates knowledge of the complete credentialing process. Participates in-services and staff development activities regarding Safety, QI and PI in all Departments. Chairs the Quality Improvement Committee. Attends management meetings and departmental meetings. Quality Assurance Acts as a consultant to all staff, physicians, managers and contracted services in understanding, implementing, and evaluating CQI activities. Assists hospital and medical staff with interpretation and compliance with State and Federal regulations. Collects data for medical staff quality improvement and attends medical staff meetings to facilitate CQI/Safety activities. Active in using and teaching others to use the CQI process to improve hospital systems and operations. Updates the organization on CQI activities and improve outcomes through attendance at department meetings and hospital newletter. Functions with an awareness and application of safety requirements as identified within the institution to promote optimum level of risk management. Assists in the control of those circumstances of hospital health care that pose a threat to the safety and comfort of patients, visitors and employees. Presents analysis of variance reports to appropriate medical and hospital departments and Physicians. Develops and implements patient assessment tools to monitor patient satisfaction. Results are communicated to appropriate departments, administration, Board and medical staff.
Functions:
Conducts monthly hospital wide Quality Improvement Committee meetings. Conducts monthly department focused QAPI meetings. Monitors patients transfers to other institutions. Monitors variance reports. Facilitates and monitors CQI meetings as necessary. Demonstrates self-directed learning and participation in continuing education to meet own professional development.
