Under the direct supervision of the Director of Quality Management, the Quality Management Manager is responsible for managing the Clinic's Quality Management Department and oversees the activities that support the department's responsibilities and initiatives. In addition, the Quality Management Manager acts an administrative representative to the Quality Management and Peer Review Committee, including appropriate sub-committees, and works closely with the Director of Quality Management, Chief Medical Officer, and Medical Directors on matters pertaining to Quality Management.
Reports to the Director of Quality Management.
Manage and coordinate the Quality Management Department.
Review laws, regulations, and current literature to determine areas that need to be assessed to ensure the Clinic is maintaining standards required by OSHA (medically related), Medicare, Public Health, Americans with Disabilities Act (ADA) and other accrediting bodies (e.g., AAAHC).
Collaborate with the Rural Health Clinic Manager to ensure the continuity of processes, policies, and procedures put into place for the purpose of compliance across multiple accrediting bodies.
Direct audit processes:
Perform research to determine criteria for audits as directed by Quality Management Director.
Direct the formatting or procedures for each specific audit.
Determine data needs for audit and direct the coordination of the data pull.
Direct the review and reporting of the data using appropriate criteria.
Provide comprehensive reports from the audit to the Director of Quality Management and the QM Committee and/or for inclusion in Rural Health books.
Direct the sending of results and expected goals of audits to providers and Operations
Coordinate educational efforts based on audit results.
Determine re-audits as needed.
Author and revise current policies regarding quality of care, regulatory compliance, infection control, OSHA compliance, employee vaccination and screening, medical record standards, and others as directed by the Quality Management or Administrative Quality Management Committees.
Forms management determining if new forms are needed, revision of existing forms, and determine if forms can be discontinued.
Facilitate all New Services requests and prepare for Committee review.
Assure all Clinic policies are reviewed/updated annually.
Function as Chairperson of the Health and Safety Committee and prepare meeting agendas and minutes.
Monitor, maintain and ensure laser safety compliance and reporting to IEMA, including laser safety on-site surveys.
Determine surveys that are needed for compliance of sites to meet regulatory and accreditation standards.
Direct surveys at appropriate sites and prepare reports of findings.
Direct creation of audit and survey forms that will facilitate ease of completing audits and maintenance of compliance with standards.
Assist with providing oversight and direction for the Clinic's PCMH, NAPBC, and QOPI accreditation.
Provide recommendations to Director of ASC to assist in meeting accreditation standards.
Directly supervise staff.
Monitor workload and available resources, assure coordination of workload, and assist in revision of department priorities with Director of Quality Management.
Manage and provide oversight to the Illinois State Cancer Registry requirements for Cancer Registrar.
Maintain all audit and survey material in a confidential manner.
Provide education to all physicians, nurse practitioners, and physicians' assistants on the Clinic standards, any areas where a provider does not meet standards, and when standards change.
Comply with the Springfield Clinic incident reporting policy and procedures.
Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
Perform other job duties as assigned.
Degree in a healthcare related field or at least 5 years experience in healthcare related quality improvement activities.
RN or LPN with license in good standing in the State of Illinois.
Knowledge of health care related laws and regulations.
Must be able to lead as well as work in a team environment.
Must have strong analytical abilities.
Strong knowledge of Microsoft Office applications.
Consistently demonstrate effective organization skills, efficiency, and resourcefulness.
Demonstrate effective relationship skills, decision-making skills and verbal and written communication skills.
Ability to present oneself and one's ideas with clarity, confidence and pride.
Must provide own method of transportation to travel to all clinic locations