The Quality Manager is responsible for the overall operations, administration and management of the services assigned, as well as the implementation of the facility’s Patient Safety and Quality Improvement Plan, Accreditation, and Performance Excellence throughout the enterprise, as documented within the published scopes and respective plan documents. The position supports and implements key operational strategies to measure, monitor and analyze the culture of safety, event reporting, identification, and mitigation of risk safety events. Provides accountability for the development of corrective and preventive actions. Evaluates the effectiveness of the event reporting system.

This individual is responsible for reviewing and formulating policy or organizational changes and making recommendations for final approval by senior leadership. The Quality Manager apprises facility leadership of significant events.

Serves as the designated Patient Safety Officer.

EDUCATION AND EXPERIENCE REQUIREMENT(S):

Bachelors Degree Required

Masters Degree Optional

SPECIAL EQUIPMENT, SKILLS OR OTHER REQUIREMENTS:

Strong written and oral communication skills, strong interpersonal, motivational and conflict-resolution skills. Strong management and administrative skills. Broad-based knowledge of hospital-related regulatory compliance requirements. Experience in expense and capital budget development and control.

WORK ENVIRONMENT AND HAZARDS:

Office and/or Clinical Setting.

PRIMARY RESPONSIBILITIES OF THE POSITION:

WORK CONTACT GROUP:

All services, employees, medical staff, patients, visitors, vendors, various regulatory and professional agencies.

Management:

Works directly with Senior team on global issues including short, mid and long-range planning and coordination.

Promotes the organization patient and colleague safety initiatives.

Partners with risk management as needed to achieve organizational goals.

Supports patient safety initiatives through direct participation on committees/task forces.

If Risk Management isn’t readily available, then ensures that patient care-related incidents are reported to The Department of Health (NYPORTS, NIMERS/JC, OMH) as required by law; directs investigation and development of corrective plans; submits required reports to state and federal agencies.

Serve as Business Owner for the event reporting system.

Serves as the lead contact for Board Quality and creates the agenda.

Directs activities associated with the implementation of the Quality Plan as documented in the system policies and procedures.

Coordinates and supports the development and maintenance of comprehensive dashboarding, and integrates system tools to support performance.

Provides reports and data relating to the ongoing status of service.

Directs the collection and submission of core measures and registry data.

Directs, manages, and facilitates the quality management system to achieve internal operational goals.

Coordinates with other services, while providing leadership and program/project development, monitoring, control, etc.

Supports and implements key operational strategies to measure, monitor and analyze the culture of safety

Provides accountability for the development of corrective and preventive actions.

Evaluate the effectiveness of the Quality Management system.

Collaborates with teams to ensure integration of high reliability practices, standard work, oversight, and reporting, ensuring continual regulatory readiness.

Directs the review and evaluation of clinical practice at the request of regulatory agencies.

Ensures effective, systematic processes are in place for continual monitoring and evaluation of clinical quality in the ambulatory and acute care areas.

Ensures a coordinated and integrated process for communication between the acute and ambulatory enterprises.

Financial:

Develops, prepares, secures approval, monitors, controls, and reports variances to the service budget (capital and expense)

Signing authority for operational expenses is $5000.

Operational:

Develops and applies the Quality Management System to measure, monitor, and maintain system requirements for regulatory accreditation and compliance. Supports the internal auditing program.

Develops, secures approval, monitors, and controls all personnel issues for the service, including but not limited to staff level, discipline issues, hire/fire recommendations, staff development, etc.

Develop, monitor, adjust and administer the organizational structure.

Provides consultation services for other services as required.

Effectively educates in a specialty area.

Adheres to hospital confidentiality statement.

Researcher:

Leads Performance Improvement and Monitoring.

Applies current concepts and findings from research and/or studies to practice.

PHYSICAL REQUIREMENTS:

Should be able to push/pull, lift/move 15 lb., be able to perform moderately difficult manual manipulations, such as using a keyboard, writing, and filing for extended periods of time, must be able to perform tasks which require hand-eye coordination, such as data entry, typing and using photo copiers. Mobility requirements may include the ability to be stationary at a workstation for a prolonged period of time in addition to being able to squat or be mobile for a reasonable length of time and distance. Communication requirements include the ability to comprehend the spoken English language in addition to being able to communicate and read the English language.

Ellis Medicine is committed to creating a diverse environment and is proud to be an equal-opportunity employer. All qualified applicants will receive consideration for employment without regard to race, creed, color, religion, sex/gender, age, national origin, disability, genetic information, predisposition or carrier status, military or veteran status, prior arrest, or conviction record, marital or familial status, sexual orientation, transgender status, gender identity, gender expression, reproductive health decisions, or domestic violence victim status.

Salary Range: $33.71-50.56 /hour Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.