Quality Assurance and Improvement Manager

Job Description

Position: Quality Assurance and Improvement Manager

Reports To: Senior Director of Operations

Job Summary: With limited supervision and broad general direction, provider for quality improvement initiatives across the entire hospital and clinic spectrum. Establishes the annual quality plan based on inputs from every department and ensures their timely reporting of data/metrics. Conducts monthly quality meetings, prepares meeting minutes, and distributes them to the appropriate departments. Conducts reviews of department practices and facilities change practices directed toward meaningful use process improvements. Responsible for keeping up with Michigan Hospital Association (MHA) for quality programs/initiatives, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and Provider applicable organization (PO). Conducts training of hospital personnel on quality practices and the use of the Plan/Do/Check/Act model and lean process improvement. Facilitates quality process improvements within and across settings to achieve coordinated high-quality care that is patient and family-centered. Performs duties as assigned.

Essential Duties and Responsibilities:

Hospital:

• Core values consistent with a patient/family-centered approach to care.
• Prepare, update and complete regulatory and quality compliance documents as requested.
• Oversee the Quality Assurance and Performance Improvement (QAPI) program.
• Lead monthly QA meetings, present reports and plans to improve quality.
• Conduct daily, weekly chart reviews, develop and implement process improvement plans to improve care and documentation throughout the departments and organization.
• Maintain databases that track quality metrics related data such as: patient satisfaction, missing documentation, transfers, etc. to analyze areas needing improvement and develop annual goals.
• Presents data and metrics per hospital standards of QA guidelines.
• Assist with tracking, analyzing, and improving assigned key performance indicators in collaboration with Administration Team.
• Ensure compliance issues, procedures, processes, and methodologies.
• Familiar with state licensure and Accreditation Commission for Health Care (ACHC) Accreditation.
• Maintains, disseminates and analyzes reports pertaining to quality and compliance issues, procedures, processes, and methodologies.
• Leads QI initiatives utilizing QI processes and assists healthcare facility teams in developing appropriate tracking metrics to monitor performance to ensure compliance with the organizational QI plan.
• Develops and analyzes Quality Assurance (QA) chart review plan and conducts QA activities.
• Demonstrates professional and effective written and verbal communication skills.
• Demonstrates a positive, respectful attitude and a keen sense for professional customer service.
• Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
• Recognizes and responds to opportunities for improvement based on established, evidence based practice. Quality focused and Community Assessment based care measures are instituted and measured.
• Provides mentoring/coaching of other population health and care coordination team members.
• Cultivates effective partnerships, effectively collaborates with all providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team members) as well as departments personnel.
• Demonstrates understanding in use of IT resources and patient databases along with electronic medical record and registry data systems.
• Demonstrate effective delegation skills to streamline operational workflows and optimize inter-office resources.
• Ensure effective tracking of test results, medication management, and adhere to follow-up appointments.
• Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records). Reports any errors/incidents discovered to Risk Management.
• Refine processes and instill critical thinking a core skills of team; capable of raising the bar for expectations for the entire organization.
• Set expectations, goals and process improvement through applying measureable methods and objectives and holds oneself and teams accountable for progress to goals and objectives.
• Develop ways to improve and streamline hospital operations and identify process improvement initiatives.
• Understand Meaningful Use and to proficient with an electronic health record along with being able to train staff in its use for effective charting and charge capture.
• Conducts annual evaluations, reports, and competencies for this position.
• Demonstrates the ability to use all channels of communication to address concerns, problems, and conflicts with other departments.

Clinic:

• Coordinate, complete, update and educate administrative team on clinical quality metrics and incentive plan process and results.
• Coordinate, monitor and evaluate medical record reviews.
• Share knowledge related to quality measures an incentive programs.
• Collaborate with Practice Manager to identify and recommend best actions for performance improvement, including developing project plans and facilitation training related to process improvement. Including developing project plans and facilitating training related to process improvement to maximize incentive program rewards.
• Perform ongoing gap analysis in clinical care and barrier to care: ensuring alignment of interventions with HEDIS, PIP payer programs and Patient-Centered Medical Home (PCMH) guidelines.
• Develop strong working relationships with all departments, providers, staff allied health care organizations and third party payer representatives.
• Works closely with Insurance plan representatives to evaluate member compliance reports each HEDIS and incentive plan measure including evaluating improvement opportunity.
• Educate and collaborate with and applicable employees on all quality measure activities including maintaining all evidences, documentations and changes.
• Work closely with IT staff to ensure that quality measure related patient visits are entered into EMR so that automatic reminders are being utilized.
• Assist with planning and implementing annual changes to the incentive plans as needed.
• Work closely with Practice Manager to maximize efficiencies in those qualities reporting initiatives that are connected with PCMH initiatives.
• Utilizes all resources to maximize patient quality outcomes thought the Michigan Care Improvement Registry (MCIR) recall process to increase compliance with childhood immunization recommendations.
• Participated in committees, in services and seminars as requested by administration.
• Utilize LEAN processes to improve processes based on the use of quality improvement data.

Qualifications

Education, Experience and Other Requirements:

• Checking hospital email at least once per work day as primary source of communication.
• Per ACHC standards, a qualified QAI Manager has formal training in principles of quality improvement to prepare for the required duties.
• Additional qualifications include: Bachelor’s degree in Nursing, behavioral science or required health care management.
• Preferred 3-5 years’ experience in quality improvements methods such as: Six-Sigma, Lean, PDCA (Black Belt or Green Belt certifications is a plus).
• Quality Improvement and Compliance knowledge preferred.
• Strong written and verbal skills and ability to communicate with a variety of people from diverse cultures, socioeconomic and educational backgrounds.
• Candidate needs to have strong skills in advanced Microsoft Excel, data analysis, and interpretation or results.
• Familiar with electronic medical records (medical records used in the organization).
• Flexibility to meet organizational needs.
• Computer skills to draft emails, memos, and reporting and have proficiency in MS suite: Outlook, Word, Power Point and Excel Pivot tables.