Black River Memorial Hospital

JOB DESCRIPTION/PERFORMANCE APPRAISAL

Job Title: Quality Manager

Employee Name:

Job Group:

Department: Quality

Pay Type:

Reports To: VP, Patient Care

Services

Created on: 09/17/07

Revised: 11/09/07, 07/07/09,

09/29/10, 05/20/11, 09/27/13

POSITION SUMMARY:
The Quality Manager coordinates the quality, patient safety and regulatory programs to
maintain a systematic, continuous team-based approach to quality and compliance within
the organization. Develops, coordinates, implements and monitors all aspects of the
hospitals quality improvement, patient safety and risk management activities. Deploys
and integrates performance improvement and quality management activities throughout the
organization. Uses constructive leadership skills to assist the organization in fulfilling its
mission and meeting established annual and long term objectives.
I. Essential Duties and Responsibilities
1. Proactively maintains the organization in a constant survey readiness mode. Ensures
the organization meets all accreditation, regulatory and quality standards for
accreditation and licensing. Coordinates all survey activity within the organization.
2. Collaborates with Senior Leaders, Managers and Medical Staff to develop and achieve
quality, safety and risk management goals for the organization in alignment with the
hospitals strategic objectives and goals.
3. Develops processes to proactively prevent risk issues. Investigates and takes
appropriate timely action(s) to resolve patient family or other customer concerns,
complaints, and problems. Manages potential and actual professional/clinical claims
and suits related to the organization by acting as the liaison to the liability carrier,
patient/family and involved practitioners.
4. Develops and manages the organizations patient/visitor relations and occurrence
reporting and follow-up programs (i.e., patient perception of care surveys, complaints,
service recovery, disclosures, RCA, FMEA, etc.).
5. Conducts or coordinates concurrent and retrospective reviews of key indicators
identified by the Medical Staff and other clinical disciplines to monitor and evaluate
clinical care, safety and service.
6. Proactively identifies and implements quality indicators to drive performance
improvement. Collaborates with Medical Staff Coordinator to establish and
implement a process for selecting criteria and monitoring data for focused and
ongoing professional practice evaluations for the medical staff.
7. Collaborates with the organizations Corporate Compliance Committee and Officer to
assure compliance with regulatory standards relating to utilization, business and
quality management principles.
8. Participates in quality, risk, patient safety, and regulatory orientation and educational
in-services for employees and physicians including the overview of the Performance
Improvement, Quality and Patient Safety Plans for the Organization.
9. Collaborates with the Data Analyst to manage the quality, risk, and patient safety
programs data collection, analysis and reporting. Coordinates organizational data
reporting requirements (TJC: Core Measures, RWHC: Quality Indicators, WHA:
Quality Initiative, AHA, etc.).
I:\HR\Performance Appraisals\Quality Manager Job Description - 09-13.doc

10. Develops and monitors the policies and procedures and budget for these programs.
Additional Duties
11. Performs other duties as assigned.
Comments:

Educational Qualifications:
Bachelor's degree in a healthcare-related field.
5 years related experience or training; or equivalent combination of education and experience.
Certification in performance improvement, quality, or comparable healthcare programs preferred.
Knowledge, Skills And Abilities Required:
Knowledge of healthcare operations, patient safety, liability, standards and regulations (business and clinical,
local, state and federal).
Knowledge or experience with the use of Baldrige Performance Excellence Criteria to drive improvement.
Excellent written, verbal and formal presentation skills.
Excellent leadership and interpersonal skills and the ability to gain the trust and respect of patients, families,
other customers, physicians, senior leadership, management, and employees.
Ability to link practice realties with theory, standards and regulations. Strong analytical and critical thinking
skills
Proficient in use of computer programs including but not limited to Word, Excel, Power Point, etc.
Work Relationship:
Reports directly to the Chief Executive Officer.
Works regularly with Senior Leadership, Department Managers, physicians, and staff from all hospital
departments.
Regular contact with patients, families, public, vendors and other community healthcare agencies.
Has regular access to highly confidential patient and hospital information.
Working Conditions:
Work is performed largely in a pleasant hospital environment with minimal chance for personal injury.
Occasionally exposed to risk of electrical shock.
Occasionally works near moving mechanical parts and in outside weather conditions.
Occasionally exposed to wet and/or humid conditions, fumes or airborne particles, toxic or caustic
chemicals and risk of radiation.
Occasionally exposed to hazardous materials such as needle punctures, blood and body fluids.
The noise level in the work environment is usually moderate.
Physical Requirements:
Frequently required to stand, walk, stoop, kneel or crouch.
Frequently required to sit.
Required to use hands to handle or feel objects, tools or controls.
Occasionally lift and/or move up to 25 pounds.
Requires specific vision abilities for far vision, near vision, depth perception, colors, accommodation and
peripheral vision.
Vision correctable to 20/40.

I:\HR\Performance Appraisals\Quality Manager Job Description - 09-13.doc

Acknowledgement:
This job description/evaluation describes the general nature and level of work performed by an employee
assigned to this position. It does not state or imply that these are the only duties and responsibilities assigned to
the job. The employee may be required to perform other job-related duties as requested by the department
manager or administration. All requirements are subject to change over time and to possible modification to
reasonably accommodate individuals with disabilities.

Employee Signature

I:\HR\Performance Appraisals\Quality Manager Job Description - 09-13.doc

Date