Quality Manager

Summary 

The Quality Manager supports the Quality team in the identification, planning and implementation of clinical quality and performance improvement efforts. Utilizes performance improvement methodology, data analysis, care facilitation, and project management skills. In addition, serves as a team facilitator and consultative resource for clinical and departmental leadership and staff responsible for quality and performance improvement activities. 

This position partners closely with Surgical Services leadership, providers, and staff to support quality improvement, patient safety, performance improvement, and regulatory compliance initiatives across the surgical service line.

Essential Duties and Responsibilities  

• Supports and promotes the mission and values of Covenant Health and the Catholic Health Ministry. 

• Able to apply the principles of project management and performance improvement. 

• Abstracts and reports quality data. 

• Accesses and uses information resources to demonstrate current practice, identify opportunities for improvement, and works toward improved outcomes.  

• Advise on future data and information needs and resources to better support performance and process improvement initiatives. 

• Use team facilitation skills and change management processes to engage others in support of the changes required to achieve performance improvement outcomes.  

• Demonstrates data management skills and the use of analytical and statistical tools.  

• Uses a range of quality improvement tools and techniques to evaluate and successfully redesign processes toward improved performance.  

• Patient Safety and Quality Accountability  

• Actively participates in the hospital’s patient safety program, ensuring alignment with organizational safety priorities and regulatory expectations.  

• Holds direct responsibility for identifying, reporting, and mitigating safety risks within assigned areas.  

• Ensures frontline staff understand and adhere to safe practices, including routine monitoring and coaching for compliance with protocols.  

• Collaborates with senior leadership and interdisciplinary teams to develop and implement safety initiatives that improve patient outcomes.  

• Maintains documentation of safety performance within their area, including tracking progress toward safety goals.  

• Participates in performance reviews and/or compensation programs that consider safety performance metrics and staff engagement in safety improvement activities.  

• Facilitates regular team communications regarding patient safety goals, progress updates, and staff education opportunities.  

• Promotes a culture of safety by encouraging event reporting, supporting just culture principles, and addressing system-level issues proactively. 

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Job Requirements 

Job knowledge and skills 

• Current computer skills, graphics, spreadsheets, and presentation software (Microsoft Word, Excel, PowerPoint, Access) 

• Able to use standard office equipment and database systems as pertinent 

• Quantitative and analytic skills relevant to the role.  

• Knowledge of clinical processes and operations in a health care system  

• Identifies and mitigates barriers that impede sustainable change 

• Critical thinking and communication skills 

• Project management knowledge and skills 

• CPHQ certification, or eligible to obtain within 2 year 

Education & Experience 

• RN with minimum five years of clinical experience. BS or BA required.  

• Quality management/QI experience preferred