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 the quality and value of the services offered to our patients.
2. Optimize MIPS, ACO and other quality metric utilization through researching CMS requirements, rewards, and consequences. Lead organizational communication of the information to managers, employees and providers after the information and organizational plan is approved by the OD and IT Director.
3. Provide leadership and guidance to managers, and assist departments with attestation/reporting for all providers in every quality program that PSC participates in.
4. Responds to any quality reporting audits with the assistance of the OD and the IT Director.
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 with IT to meet CMS attestation/reporting for all quality reporting programs.
1. Chair monthly Clinical Excellence Committee: prepares agenda, materials and minutes.
2. Monitor satisfactory completion of clinical projects and tasks with the department managers and lead staff.
3. Support monthly Quality Operations Committee as needed. Help OD with QOC packet materials.
4. Facilitate and leads the MIPS 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. Annually review and modify as needed and required by our AAAHC accreditation patient care policies and procedures. Submit updated or new policies to OD for approval prior to submission to the QOC and medical director.
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. Lead AAAHC survey activities for the entire organization.
6. Support operational process improvement through management reporting and analysis; of charting deficiencies and other reports on a monthly basis. Must understand how to proficiently use Excel spread sheets, use formulas and create pivot tables.
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. Nursing license required; RN preferred
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 to help the organization be successful in MIPS or other quality reporting programs
6. Training and presentation experience
7. Experience in deploying clinical quality improvement programs
8. Detail oriented
9. Highly skilled in Excel
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.