RN Manager Quality & Safety

General Summary of Position
The Quality & Safey (Q&S) Manager manages quality improvement projects in alignment with MedStar Health's goals and objectives and is responsible for operationalizing MedStar Health's Patient Safety Management Program. In this role the Q&S Manager ensures that the operations improvement planning and implementation of quality improvements/patient safety are developed initiated and supported. The Q&S Manager leads event review processes oversees the management of patient safety event reports facilitates the design and implementation of safety improvement activities fosters and monitors just culture and psychological safety across the entity and leads efforts to reduce risk of patient harm within their entity. To ensure success the Q&S Manager develops strong working relationships with system quality & safety leaders key stakeholders within the entity and with system and entity Risk Management leads.

Primary Duties and Responsibilities

• Collaborates with clinical and operational teams to design quality improvement interventions focused on key quality and safety priorities and drives entity level execution of those interventions
• Assists in the development of monitoring systems and tracks outcome data to evaluate successful implementation of quality improvement initiatives including but not limited to publicly reported measures CMS programs reputational programs and other regulatory requirements Remains knowledgeable of all relevant clinical pay for performance and reputational program methodologies and updates
• Operationalizes the overall patient safety strategic plan for MedStar Health with a focus on promoting safety reporting fostering psychological safety and just culture facilitating systems-based event reviews tracking safety metrics and training MedStar Health associates and leaders about safety science.
• Coordinates the review and management of patient safety events (PSEs) with significant risk or harm including SUOs and SSEs. Ensures necessary peer reviews are completed for cases as appropriate and supports the implementation of risk mitigation strategies and monitoring effectiveness and sustainability.
• Contributes to the achievement of established departmental goals and objectives and adheres to department policies procedures quality standards and safety standards. Ensures compliance with entity/facility policies and procedures and governmental/accreditation regulations.
• Implements monitors and provides education to hospital/ambulatory/medical staff regarding the MedStar Health Patient Safety Management Program safety performance improvement efforts event management safety metrics among other issues.
• Continuously assesses and executes a safety culture program aligned with the MedStar Health approach. Leads key safety culture initiatives and ensures entity compliance.
• Collaborates with and maintains effective communication with the entity VMPAs/CMOs CNOs and other leaders throughout the system regarding departmental activities and execution of risk reduction strategies and support safety initiatives.
• Contributes actively to the dissemination of Medstar Health quality and patient safety practices and accomplishments through presentations at professional meetings and educational offerings and through publication in peer-reviewed journals and other academic publications.
• Identifies opportunities for quality and safety improvement and develops action plans to address gaps in collaboration with clinical and operational leaders. Partners with local and system leadership to facilitate task forces and councils coordinating the planning implementation and execution of quality and safety improvement initiatives
• Manages the revision formulation and review of policies and procedures. Oversees operational dashboards for outstanding and ongoing projects quality and safety issues and challenges. Drives change by developing standardized processes to manage issues to completion and executing towards the achievement of department goals.
• Prepares and reviews reports and analysis of quality and safety data for the system leadership the VPMA and other key stakeholders.
• Participates in local and system level meetings and committees and represents the entity in community outreach efforts.
• Participates in multi-disciplinary quality & safety improvement teams.

Minimal Qualifications
Education

• Bachelor's degree in nursing or healthcare related required or
• Master's degree in nursing or healthcare related preferred

Experience

• 3-4 years Clinical and / or health care experience required and
• 1-2 years Quality and Safety experience required and
• 1-2 years in nursing leadership required

Licenses and Certifications

• CPHQ - Certified Professional in Healthcare Quality preferred
• CPPS - Certified Professional in Patient Safety preferred

Knowledge Skills and Abilities

• Ability to review clinical content with strong analytical and quantitative skills.
• Exhibits excellent organizational and planning skills with a high level of problem-solving skills.
• Ability to comprehend and follow the policies and procedures for MedStar Health and the applicable MedStar Entity.
• Ability to read write and speak or communicate in English to successfully accomplish the essential duties of the position.
• Ability to demonstrate ethical behavior that supports the entity's mission values and commitment to compliance with all federal state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities.
• Exhibits professionalism courtesy and excellent customer service while interacting with patients guests and co-workers.
• Ability to work effectively with people from a variety of culturally diverse backgrounds.
• Knowledge and skill to demonstrate strong leadership and management qualities (task completion delegation motivation supervision).
• Knowledge and skill of patient safety principles tools methods and frameworks.
• Ability to work with a variety of disciplines and levels of staff across the department and the health system is required.
• Effective organizational oral and written communication skills problem solving program development computer skills strong leadership and team building skills.