Manager of Quality

Do you have the career opportunities as a Manager of Quality you want with your current employer? We have an exciting opportunity for you to join Methodist Hospital Specialty and Transplant which is part of the nation's leading provider of healthcare services, HCA Healthcare.

Job Summary and Qualifications

Provides oversight for development and implementation of quality improvement and regulatory compliance. The position owns the analysis of quality and performance improvement data for the organization through coordination of information including data collection, analysis, and trending of data, compliance with required regulatory indicators, and external agency review and other select clinical outcomes measurement. Provides expertise and leadership in maintaining compliance with requirements of regulatory and accreditation agencies including The Joint Commission, CMS, TDSHS and other applicable agencies. This position serves to educate staff and physicians on regulatory/accrediting requirements to promote readiness and compliance.

Essential Job Functions:

• Coordinates the Quality Assessment/Performance Improvement (QAPI) program and oversees the collection, aggregation and analysis of data for the program.
• Coordinates Quality Council and CART Meetings in addition to serving Nursing Committees. Assists the Chair of the Quality Council, hospital leadership and staff to identify opportunities and develop action plans to drive improvement of patient care, treatment and services. Provides expertise and acts as a coach to PI teams chartered by the Quality Council.
• Measures, analyzes, generates and presents reports on healthcare processes and patient outcomes to identify and prioritize areas for improvement.
• Works in conjunction with Patient Safety/Risk Management in analyzing and responding to significant preventable adverse events (SPAEs) and unanticipated outcomes that occur. Assists with process improvement initiatives resulting from event analysis.
• Maintains knowledge of and expertise in requirements related to The Joint Commission, Medicare (CMS) Conditions of Participation, and Texas Department State Health Services. Develops and implements action plans in response to survey/review findings.
• Oversees all preparation and reporting activities related to regulatory requirements. Coordinates scheduling and activities of announced surveys/reviews and activities for unannounced surveys/reviews; acts as interface with regulatory agencies. Ensures continuous compliance with all requirements; oversees policy development, review and revisions necessary to maintain regulatory compliance.

• Bachelor degree is required
• Bachelor of Science degree in Nursing or other health related discipline is preferred.
• Graduate degree preferred such as an MBA, MSN or MHA.
• Three years of clinical, quality or regulatory experience required; clinical, quality or regulatory experience in transplant services preferred.
• Experience or training in principles of quality improvement and regulatory compliance preferred.
• Strong analytical and critical thinking skills and experience in utilizing work processing, spreadsheets, and clinical systems/databases required.
• Employee completes initial and ongoing training and competencies as defined by service line, facility and department/unit which are specific to the needs of the patient population served (if applicable).
• Required: Current Texas licensure as a registered nurse, other clinical discipline OR Certification as a Certified Six Sigma Professional (CSSC).
• Preferred: Certification as a Certified Professional in Healthcare Quality (CPHQ) preferred.

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services
• Wellbeing support, including free counseling and referral services
• Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts