Trauma Quality Manager, Jackson Memorial Hospital, Full Time, Days

Summary

The Manager Quality, under the direction of the director of quality, is responsible for developing, coordinating, implementing and evaluating the continuous quality improvement activities for the quality program. Facilitates and monitors patient safety activities and acts as a resource to the quality team and responsible in educating best practice standards of care, promotes continuous readiness and is responsible for reporting quality indicators in department meetings. Leads the quality team on continuous quality improvement projects using approved tools, designed control, validations, and ensuring adherence to agency regulations.

Responsibilities

• Performs ongoing analysis of gaps and clinical and barriers to care and collaborates with risk management to perform root cause analysis (RCA) as needed; ensuring alignment of all intervention with organization’s quality strategic plan. 
• Oversees, coordinates and implements regulatory activities and site reviews as required including AHCA/CMS, Joint Commission, and other regulatory agencies. 
• Implements quality improvement activities based on data and outcomes for the quality management within the Facility. 
• Ensures all departments comply with and understand the quality program, reporting elements, and regulatory requirements. 
• Assists in designing and implementing quality and performance improvement projects including valid and reliable indicators. 
• Responsible for real time tracking, trending, interpreting and sharing quality outcomes data along with recommended follow up plan of action and resolution based on the highest quality outcome. 
• Assists in staff participation on outreach program activities to support quality and safety prevention initiatives in the community. 
• Coordination, monitoring and evaluation of medical record reviews/audits. 
• Assists in updating, reviewing and revising policies and procedures as needed. 
• Develops strong working relationships with the departments, divisional teams, and the medical staff. 
• Duties that may apply to incumbents at JS, JN and JW includes but not limited to assist in abstractions of core measures and responsible for keeping self-up to date with changes in the core measures specifications for abstractions. 
• Under the direction of the director of quality, is responsible to facilitate all aspects of the peer review process in collaboration with the Chairperson of the Peer Review committee and or designee. 
• Develops and maintains an effective working relationship with the Medical Staff leadership providing the necessary support pertaining to the peer review process. 
• Reviews cases referred for Peer Review. 
• Coordinates the Peer Review Committee meetings and other related functions of the committee. 
• Reviews mortalities, and morbidity cases as assigned. 
• Maintains PI Board of the units as needed. 
• Responsible for performing tracers and preparing assigned units for continuous survey readiness. 
• Role models behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). 
• Performs all other related job duties as assigned.

Experience

• Generally requires 3 to 5 years of related experience. 
• Supervisory experience is preferred.

Education

• Bachelor's degree in nursing or healthcare field is required. 
• Master's degree is preferred.

Credentials

License as a professional registered nurse or any other type of healthcare practitioner license is strongly preferred.

Unit Specific Credential

AHA Basic Life Support (BLS) with 6 months validity

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.