QAPI Clinical Service Ln Mgr. Partial Remote (Sealy Heart & Vasc. Inst. - Galveston)

Minimum Qualifications:

Bachelor degree in Nursing, Healthcare Administration or related clinical program field

Eight (8) years of experience directly related to quality/performance improvement functions within a healthcare setting:

LICENSES, REGISTRATIONS OR CERTIFICATIONS

Required:

Valid state of Texas Professional Nursing (RN) license or clinical program professional registration

Preferred:

Six Sigma Green Belt or Certified Professional in Healthcare Quality (CPHQ) certification

JOB DESCRIPTION

Scope: The QAPI Manager, Clinical Services is a designated member of the clinical team and is responsible, under the guidance of the Department Administrator, for overseeing and continually evaluating the effectiveness of the operational components of the QAPI plan including metric development and selection, data capture, data analysis, opportunity identification, and ongoing operational survey readiness for all regulatory bodies. They are responsible for independently implementing initiatives aimed at improving quality outcomes.

Function: This individual is tasked with developing and maintaining the QAPI program and an educational framework that ensures all clinical programs and other hospital department staff have knowledge of new and existing regulatory requirements related to quality and patient safety. They will serve as the key liaison during survey activities.  They will also serves as advisor and subject matter expert in Joint Commission, CMS, Texas Department of Health and Services and other regulatory agency standards and policies. The manager oversees staff that aid in developing and implementing new programs aimed at improving or maintaining departmental effectiveness and efficiency, and reviews identified opportunities for improvement. This individual supervises designated support staff.

ESSENTIAL JOB FUNCTIONS

Quality:

• Oversees all collaboration with medical staff and operational leadership to facilitate evidence-based quality and patient safety initiatives; engages associates at all levels in continuous pursuit of improvement opportunities.
• Provides project management and facilitation, as well as, oversight and support for key functions and processes for the systematic, coordinated, and continuous improvement of patient care delivery.
• Ensures quality and performance improvement initiatives are aligned with regulatory standards and healthcare best practices and reporting of quality outcomes and performance improvement initiatives.

•  Ensures the integration of aggregate data into performance improvement planning and problem resolution.

•  Monitors the use of statistical process tools and process improvement methodologies used to ensure continuous improvement in patient care and outcomes.
• Evaluates the relationship of quality and performance improvement initiatives with patient outcomes to determine if desired results have been achieved or sustained.
• Compares performance data and outcomes with authoritative external sources and benchmarks.
• Organizes and leads relevant task forces or work groups, for reviewing evidenced based literature/benchmarks, and suggesting revisions/additions to the indicators for monitoring and evaluation of quality, regulatory and accreditation goals and objectives
• Prioritizes and sets strategic direction for improvement efforts based on alignment with health system and transplant program goals, as well as, clinical performance with regard to pati