QUALITY IMPROVEMENT MANAGER in Chicago, Illinois at Sinai Chicago

Position Purpose: The Quality Improvement (QI) Manager leads the development, facilitation, and coordination of quality improvement programs (clinical, operational, and service line) resulting in high reliability, improved patient care, operations, and patient experience. This position collaborates with hospital and medical Staff on projects and quality initiatives relating to improved operations, processes, and procedures and to elevate clinical excellence. Additionally, this role facilitates activities associated with the Core Measures program including abstraction management and oversight of associated databases and systems. This position assists with the completion of the medical staff peer review process.

Position Purpose:

The Quality Improvement (QI) Manager leads the development, facilitation, and coordination of quality improvement programs (clinical, operational, and service line) resulting in high reliability, improved patient care, operations, and patient experience. This position collaborates with hospital and medical Staff on projects and quality initiatives relating to improved operations, processes, and procedures and to elevate clinical excellence. Additionally, this role facilitates activities associated with the Core Measures program, including abstraction management and oversight of associated databases and systems. This position assists with the completion of the medical staff peer review process.

Key Job Activities:

• Identifies best practice and leads interdisciplinary teams to implement improvement to achieve high reliability and zero harm.
• Facilitates, leads, and collaborates on Quality Performance Improvement projects to align strategic priorities, interventions, and standard work to harmonize system-wide approaches where appropriate.
• Partners with departments and service lines to identify best practice to close gaps and utilize a data-driven approach to improvement.
• Leads performance improvement projects using data analysis skills and tools to determine priorities for improvement, clinical or business process knowledge to know where efficiencies and workflows can be improved and rapid improvement cycles.
• Creates action plans and communicates status to improve key systemwide metrics and track implementation, effectiveness, and compliance to assure accountability.
• Co-leads assigned clinical department quality meetings by planning the meeting agenda, clinical data presentation, identification of areas of improvement based on current metrics and best practice, and minutes preparation in collaboration with department chairperson and clinical analytics. Responsible for understanding data analysis, core measures or applied metrics and communicating quality information to individuals and groups.
• Assures and maintains compliance with regulatory standards related to quality and patient safety.
• Serves as a role model for quality excellence, performance improvement, and a culture of safety.
• Demonstrates current knowledge of QI principals, tools and concepts and a commitment to continued learning as identified by system goals and department-specific needs.
• Trains leadership, caregivers, and physicians on the use of quality and performance improvement methodology and their respective responsibilities in carrying out the program.
• Manages medical staff Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE), and peer review program and assures consistent application across sites and disciplines.
• Supports the organization’s drive to achieve and maintain top-degree performance as measured by Leapfrog, Value-Based Purchasing, CMS, and other publicly reported methodologies.
• Reviews assigned quality cases such as mortality reviews, patient safety indicators, hospital acquired conditions, and other quality indicators. Completes reports in a timely manner.
• Facilitates activities associated with the Core Measures and other reportable measures program including data collection, abstraction management and oversight of associated databases and systems, working with multidisciplinary teams including physicians, coding, analysts, and nursing.
• Develops and presents quality improvement presentations and dashboards for system, hospital and medical staff committees and assists in their preparation for board meeting presentations.
• Utilizes and prepares performance improvement tools such as flowcharts and FMEAs, and interprets results using control charts and other data analysis tools.
• Demonstrates ability to adapt to emergent requirements for quality and patient safety initiatives.
• Facilitate daily system-wide patient safety huddle.
• Performs other duties as assigned.

Education and Work Experience:

• Bachelor’s degree in a health-related field required, a master’s degree preferred.
• Three years of related healthcare experience are required.
• Experience using Lean, Six Sigma, or other performance improvement methodology.
• Experience with peer review, mortality review, and chart abstraction for publicly reported quality measures.
• Clinical experience preferred.

Knowledge and Skills:

• Effective communication, interpersonal, organizational and facilitation skills.
• Proficient computer skills with extensive experience using various software applications such as
• MS Excel, Word, Access, PowerPoint, Visio; relational database structures and reporting software.
• Knowledge of quality improvement tools, principles and practices including project management, patient safety concepts, public reporting, data analysis, and statistical analysis in healthcare
• Previous experience with facilitating and coordinating healthcare quality improvement projects, working with multidisciplinary teams and holding owners accountable.
• Knowledge of external regulatory and accreditation agency rules and regulations.
• Experience with clinical/healthcare software applications preferred; demonstrated knowledge and skills in statistical packages and concepts including control charts.
• High degree of creativity in problem-solving.
• Experience in EPIC and MEDITECH software systems preferred.

Certifications/Licenses:

• CPHQ is required within two years of employment.