Quality Manager RN
Shawnee, KS 66214 US
Quality Manager RN - Inpatient Psychiatric
$73K - Negotiable
20 bed Geri-Psych facility
Inpatient Psychiatric facility
MUST be an RN BSN or MSN
The Manager of Quality & Risk Management is responsible for administering and monitoring the hospital’s readiness of quality management and quality improvement processes for all departments of the hospital. Manager of Quality & Risk Management also oversee the Infection Control services for patients, visitors and staff members. The incumbent provides leadership for process improvement initiatives that align with the organization’s strategic goals to improve quality outcomes while maintaining compliance with all regulatory, state, federal and Joint Commission standards.
a. Provides leadership for the implementation of the organization's quality improvement program and plan in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, accreditation standards.
b. Responsible for interpreting, supporting, and executing hospital and department policies, and procedures.
c. Conduct regular rounds in hospital departments and hospital milieu for monitoring the practices of staff such as patient safety, patient engagement, infection control and other rounding tasks as assigned. Provide necessary ad hoc education as needed.
d. Collect data on infections from hospital departments and maintaining records for every case.
e. Conduct training sessions to ensure constant implementation of infection control practices.
f. Monitor the execution of infection preventive measures and providing guidance to staff.
g. Participate in unit meetings, in-services education programs, and quality improvement initiatives as assigned.
h. Participate in Infection Control and Quality and Safety Committee meetings and communicates infection outbreaks directly to the Director of Nursing.
i. Ensure that the staff and patients are free from any infectious disease.
j. Works collaboratively with and oversees the infection control consultant to ensure patient and employee safety processes.
k. Ensure patients are offered influenza and pneumococcal vaccination.
l. Monitor annual influenza vaccination is administered timely ensuring all employees received vaccination, unless otherwise, contraindicated. Ensure students, trainees, volunteers, providers with hospital privileges and contracted services personnel with direct patient contact provide proof of current influenza vaccination. Prepare a report on annual influenza vaccination rate for the hospital.
m. Monitor and prepare reports on the companies Quality Metrics/Measures monthly, quarterly, and annually for Infection Control, Utilization Review, Pharmacy and Therapeutics, Pain Assessment and Management, Opioid Usage and Management, Data Management, Patient Satisfaction, Employee Safety and Satisfaction, Discharge Planning, Grievances/Complaints, Restraints and Seclusion Usage, Mortality Review, State Reportable, adverse events, sentinel events, patient safety and other reports as assigned.
n. Prepare and submit required incident data report and reportable incident report to the applicable state health department.
o. Complete and submit HBIPS quarterly report.
p. Responsible for Press Ganey entries.
q. Generate and maintain PIPs and PIP updates.
r. Perform chart audits on the following but not limited to patient admission ensuring admission packet is accurate and complete, physician orders and MAR transcription accuracy, nursing assessment, master treatment plan, nursing treatment plan and behavioral treatment plan, nursing notes, techs rounding forms, photos, discharge summary, physician evaluations and progress notes and consents.
s. Review all incident reports and create incident report log.
t. Identifies evidence-based research, best practices, and/or data driven opportunities for improvement in new and existing work processes, procedures, and services to improve patient care outcomes in collaboration with the clinical team. Outcome and process measures are based on evidenced based medicine and best practices.
u. Provides leadership in performance measurement analysis, trending and the utilization of benchmarking data to facilitate decision making for improvement.
v. Leads, facilitates, and advises internal quality improvement teams and QAPI initiatives.
w. Facilitates nursing education and training of quality and safety improvement processes and tools.
x. Works collaboratively with the healthcare team to mitigate risk to patients, families, visitors, employees, physicians and the hospital system.
y. Provides support during regulatory surveys/audits as necessary.
z. Demonstrates a mastery of the standards of the Joint Commission, Centers for Medicare and Medicaid Services (CMS), and the State Department of Mental Health.
aa. Works with interdisciplinary teams to facilitate accreditation and regulatory compliance.
bb. Works the floor and provide direct patient care when needed and be part of hospital on-call rotation.
cc. Responsible for quality data submission for regulatory and accreditation organizational compliance reporting and for external quality reporting for state and national quality improvement initiatives.
dd. Other duties as assigned.
Education: Must have a Bachelors of Nursing degree. Master’s degree preferred.
Requires 3-5 years of experience as a Registered Nurse, with a minimum of three years’ experience in healthcare quality and performance improvement. Requires the ability to apply knowledge of personnel policies and procedures; strong customer service skills; high level of interpersonal, problem solving and analytical skills. Progressive leadership experience.
Licensure: Currently licensed in the State of Kansas as a registered nurse. Certified Professional in Healthcare Quality (CPHQ) preferred. Certified in Basic Life Support.
Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws as well as regulations and hospital policies that apply to assigned duties, and in specialty area via professional organizations and other resources.
Complies with hospital expectations regarding ethical behavior and standards of conduct.
Complies with federal and hospital requirements in the areas of protected health information and patient privacy.
Some duties may be reassigned and other duties may be assigned as required in the hospital's sole discretion.