Manager, Quality Improvement

Title: Manager, Quality Assurance

Location: Laguna Hills, CA

Department: Quality Assurance

Status: Full Time

Shift: Days

Pay Range*: $60.81/hr - $91.21/hr

At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

Position Summary

This position requires the full understanding and active participation in fulfilling the mission of MemorialCare Saddleback Medical Center. It is expected that the employee demonstrate behavior consistent with our core values: Integrity, Accountability, Best Practices, Compassion and Synergy, and role models customer service attributes. The employee shall support MemorialCare Saddleback Medical Center’s strategic plan and participate in and advocate performance improvement and patient safety activities.  

The Manager of Quality Improvement will work collaboratively with the Executive Director of Quality to oversee all clinical quality and performance improvement initiatives for Saddleback Medical Center. The manager provides leadership for quality data and performance improvement in the development, implementation, measurement, and monitoring of strategic initiatives that ensure that clinical quality outcomes are being met.  This position provides day-to-day departmental leadership for the Quality Assurance and Patient Relations departments.  The focus of this position is on achieving excellent patient care outcomes, decreasing patient harm and adverse events, and identifying performance improvement opportunities to optimize patient care.  The manager is responsible for the patient experience, including oversight of patient and family grievances and complaints and the patient experience improvement initiatives.  The manager will oversee development, initiation, and sustainment of performance improvement initiatives in quality, patient safety, and patient experience.

Essential Functions and Responsibilities of the Job

1.In collaboration with the Executive Director of Quality, the manager will position Saddleback as a national leader in clinical Quality performance metrics.

2.Develops and implements quality improvement plans in alignment with the hospital’s strategic plan and goal.

3.In collaboration with the Executive Director of Quality, the manager will advance Saddleback in the High Reliability Organization (HRO) maturation journey.

4.Provides Lean Leader Certified oversight of the organization-wide performance improvement and patient safety plans for SMC.

5.Analyzes clinical data and performance metrics to identify areas of improvement.

6.Ensures compliance with all federal, state, and local healthcare quality and safety standards and regulations.

7.In collaboration with the Executive Director of Quality, the Manager of Quality Improvement will advance SMC’s patient experience.

Operations:

1.Actively participates on quality, patient safety and patient experience committees.

2.Collaborates with medical staff leadership, physicians, nursing leadership and ancillary leadership to identify and implement best practices and performance improvement opportunities.

3.Participates in quality related projects or training throughout the organization.

4.Supports the strategic plan and the goals and direction of the performance improvement plan.

5.Oversees and improves data monitoring tools and metrics for analyzing and reporting data to enhance quality initiatives including but not limited to quality outcomes, patient safety, and patient experience.

6.Implements best practices in accordance with the hospital policies and submits presentations on behalf of MemorialCare at state and national meetings.

7.Directs quality and patient safety educational projects on performance improvement methodologies for physicians, clinicians, and staff.

8.Ensures cost-effective daily operations and allocation of resources.

9.Hires, develops, and maintains the performance and competence of department staff.

10.Manages and oversees quality improvement projects, ensuring they are completed on time and within budget.

Regulatory:

1.Actively participates in continuous regulatory/survey readiness.

2.Assists with plans of correction and performance improvement activities related to regulatory requirements.

Patient Relations:

1.Provides direct oversight of the hospital grievance and complaints process, including facilitating the Grievance Committee, and investigation, coordination, communication, resolution and responses processes.

2.Ensures compliance with all regulatory requirements for all grievances and complaints.

3.Reviews patient feedback and complaints to identify potential areas of improvement in patient care and satisfaction.

4.Provides oversight for the Simply Better Trust and Service Recovery initiatives.

5.Provides oversight for patient satisfaction survey process and publicly reporting data, track/trend performance, identify opportunities for improvement and implement action plans.

*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Minimum Requirements

Qualifications/Work Experience:

Minimum of two (2) years of experience in the areas of quality management, performance improvement, patient safety, data analytics, database management, or patient experience required

Minimum three (3) years of experience in leadership role with direct reports required

Excellent communication, interpersonal, and presentation skills

Knowledge of quality management principles, tools, and methodologies

Comprehensive knowledge of regulatory requirements and accreditation standards (e.g. Joint Commission, CDPH, CMS   Conditions of Participation)

Strong computer, data analysis, communication, and project management skills

Proficient in Microsoft Office and quality management software tools

Education/Licensure/Certification:

Bachelor’s degree required

Master’s degree in Healthcare Management, Nursing, Public Health or related field preferred

Current California RN licensure required

Certified Professional in Healthcare Quality (CPHQ) or other related certification preferred