The Clinical Quality Manager assumes leadership responsibility for the assessment, development and implementation of clinically effective systems within the continuum of care. Works in partnership with the operations director and department managers to develop strategies that create and sustain a culture of clinical excellence. Ensures adherence to established clinical policies, protocols, regulations, and standards. Applies knowledge of nursing and clinical data management to assist in the design, development, and ongoing modification of computerized health care systems.
Areas of Responsibility
1. Lead quality measurement and reporting program focused on improving quality and value in the services offered.
2. Optimize Meaningful Use, PQRS, and other quality metric utilization through researching CMS requirements, rewards, and consequences and communicating the information with employees and providers.
3. Provides leadership, guidance, and assist to the departments with attestation for all providers for every quality program such as meaningful use, PQRS, etc.
4. Respond to any quality reporting audits.
5. Support EMR based workflow analysis to maintain standards and process integrity while optimizing efficiency and effectiveness.
6. Establish clinical reporting requirements with an emphasis on streamlined, standard reporting to minimize special requests.
7. Collaborates for IT to meet CMS attestation quality reporting requirements.
1. Chair monthly Clinical Excellence Committee: prepares agenda, materials and minutes. Monitors satisfactory completion of projects and tasks.
2. Support monthly Quality Operations Committee as needed.
3. Facilitate and leads the Meaningful Use portion of the Clinical Quality Meeting.
1. Institute clinical quality monitoring and measurement systems by benchmarking Pinehurst Surgical services and work processes to similar organizations to identify best practices for the purpose of continuous quality improvement.
2. Serves as the clinical consultant for program/service development, other projects, policy, procedures and educational/training programs.
3. Review and modify as needed patient care policies and procedures.
4. Collaborate with Operations Director in the development and execution of improvement plans to prevent sentinel events and incidents that impact clinical quality including patient complaints concerning clinical standards or outcomes.
5. Ensure compliance with all applicable AAAHC standards. Leads AAAHC survey activities
6. Support operational process improvement through management reporting and analysis; charting deficiencies.
7. Ensure compliance with Patient Care, Infection Control, Quality and OSHA policies and procedures.
8. Develop curriculum and training to promote clinical excellence among clinical staff.
9. Respond to emergency Code situations. Conducts follow-up assessment on codes to pursue continual improvement.
10. Other duties as assigned.
1. Registered Nursing license required
a. Not less than 3 years clinical experience
b. BLS certified required; ACLS preferred
2. Extensive experience with EMR utilization and implementation
3. Experience in ensuring compliance with clinical regulations and standards
4. Quality measurement, reporting and data analysis
5. Extensive experience with meaningful Use, PQRS and other quality reporting
6. Training and presentation experience
7. Experience in deploying clinical quality improvement programs
8. Detail oriented
Accountable to the Operations Director
No direct reports.
Physical guidelines include ability to work at a computer terminal for up to eight hours.
Ability to respond quickly to clinical emergencies.