Quality- Program Manager - Trinity Health System

• The primary function of the Quality/Patient Safety/Infection Prevention Program Manager is to support, coordinate, and facilitate the quality management (QM), patient safety (PS), infection prevention (IP) and regulatory performance improvement (PI) activities for the hospital and medical staff. This role also serves as a resource to employees, management, nursing directors, senior management, councils, physicians and teams on quality management activities and will handle patient sensitive and confidential hospital information.

• Collaborates with the department leader in all infection prevention related activities associated with surveillance, performance improvement, and education which are intended to ensure that the facility’s patients, personnel, and visitors will be protected from transmission of diseases and infection within the facility’s environment as identified in the core competency model by the Association for Infection Control and Epidemiology (APIC).

• Assists in the design, planning, implementation and coordination of QM, PS, IP, and PI activities for assigned hospital and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, and root cause analyses and medical staff improvement (e.g. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review.
• Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures. Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement, perform data collection and abstraction per specifications, and validate data prior to submission or preview reports prior to publication.
• Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.
• Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers.
• Responsible for assisting the department to ensure compliance with Hospital Accreditation Standards, State and CMS regulations, and for the daily operations of the Infection Prevention Department.
• Assists the department leader with ongoing assessment and development of programs, policies and procedures, and forms to address the Infection Prevention needs of employees, volunteers, contract workers, independent contractors, physicians, registry workers, and students in accordance with the guidelines established by the regulatory agencies.
• Oversees and monitors the clinical work of staff. Identifies competency and training needs. Coordinates and oversees training. Utilizes senior area staff to assist with training and provides clinical expertise.
• Identifies and implements updates to the Infection Prevention Program when new regulations and/or professional guidelines are published.

Minimum Qualifications

Required Education and Experience

• One (1) year healthcare-related quality management/performance. Bachelor’s degree or five (5) years of related job or industry experience in lieu of degree.

Required Licensure and Certifications

• Current state license in a clinical field in state of practice (OHIO). Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

Required Minimum Knowledge, Skills, Abilities and Training

• Knowledge of effective self-management practices and ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Understanding of the necessity and value of accuracy and attention to detail; ability to process information with high levels of accuracy.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Knowledge of major functional processes and associated operating requirements; ability to apply this knowledge appropriately to diverse situations.
• Knowledge of the current situation or issue at hand; ability to take full personal responsibility or ownership for assignments, activities, decisions and results.
• Demonstrates breadth and/or depth of professional/technical skills and capabilities required for position; shares knowledge; sets or contributes to the Company’s direction within area of expertise.
• Keeping the organization’s mission, vision and values at the forefront of associate decision making and action.
• Ensuring that the patient/customer perspective is a driving force behind our actions and business decisions; crafting and implementing service practices that meet patients'/customers and own organization’s needs. (Focus also includes internal and external customers.)
• Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
• Knowledge of the critical interdependencies among system elements that help and hinder performance and ability to plan and design solutions that synchronize resources to achieve business results.
• Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities.
• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks.
• Knowledge of purpose and impact of The Joint Commission; to continuously improve the healthcare for the public, in collaboration with other stakeholders, by evaluating health care providers and inspiring them to excel in providing safe and effective care at the highest quality and value and the Center for Medicare and Medicaid Services (CMS). This also includes (PTAC) Professional Technical Advisory Committees.
• Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions that resolve the problems in the best interest of the business.

PI242004963