The Infection Prevention & Quality Manager (QM) is accountable for management and oversight of the Integrated Quality Services (IQS) Department. Duties include planning, coordinating, and providing guidance for the integrated functions of quality assessment and improvement, patient safety, medical staff services, accreditation and licensure and infection control within the Quality Management Department. The Quality Manager serves as the hospital's Patient Safety Officer, Infection Preventionist, and provides coordinated services with the Healthcare Risk Services.
Functions as the organization's Infection Preventionist to ensure appropriate surveillance, mandatory reporting and activities aimed at the prevention of healthcare associated infections (HAI).
Assimilates information to proactively develop quality activities aligned with SCP's strategies and values. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on all aspects of the quality program to develop and influence improvement strategies. Provides facilitation and support to all departments of the facility for the CQI program, including data collection, analysis and reporting.
Has significant responsibility for the organization's pursuit of operational improvements and efficiencies as it impacts quality and safety of care. Utilizes LEAN and other improvement methodologies, supporting the development and implementation of clinical assessment/process improvement and redesign. The QM leads and participates on teams that identify the best known clinical and operational practices to achieve and retain optimal quality outcomes.
This position is responsible for interpretation of legal and regulatory requirements, including, but not limited to the Centers for Medicare and Medicaid Services, The Joint Commission, and California Code of Regulations pertaining to hospitals. The manager is accountable for facility preparedness for regulatory and accreditation agency surveys. Provides organization-wide leadership for the development, implementation, coordination, and evaluation of the performance improvement activities and resources to support compliance with standards and regulations.
Oversees personnel and activities of the Medical Staff Office in accordance with bylaws, rules and regulations. Collaborates with Healthcare Risk Services to support provision for cross-coverage for risk duties. Oversees the hospital's Patient Safety program.
The Manager has the authority to approve budget expenses for the IQS Department and all associated cost centers. Has authority to schedule work hours, approve overtime, coach, and counsel staff. Decisions to hire, discipline, and terminate positions that report directly are made in collaboration with the SHVA Director IQS Operations and Hospital administration. The incumbent and must operate within policies and procedures, philosophy, and objectives of the Hospital, and applicable regulatory agencies. Initiates, approves, and secures Policy and Procedures related to areas of responsibility. . The incumbent is accountable for complying with the SHVA Standards of Behavior. This position works directly with the Administrative Team, Medical Staff and other management staff within the assigned hospital. Works directly with SHVA Integrated Quality Services, including the SHVA Director IQS Operations, and other SHVA Quality and Safety Directors and Managers. Maintains working relationships with peers within Sutter Health.
+ Bachelor’s Degree in a healthcare field related field or non-healthcare related field with acute care experience required.
+ Master’s Degree preferred.
**LICENSURES AND CERTIFICATIONS:**
+ Certified Infection Control – CIC is required within 3 years of start date.
+ Registered Nurse - State Licensure – is required.
+ Certified Professional Healthcare Quality RN - CN-PH QUAL is required within 3 years of start date.
+ Quality management, accreditation and licensure, process improvement, or infection prevention in an acute care setting.
+ Applicable experience including managing CQI systems for medical staff and hospital staff, responding to patient grievances, or processing legal claims.
+ Demonstrated ability to analyze clinical data and recommend/implement appropriate action plans.
+ Prior experience in The Joint Commission survey preparation and response for infection control and/or hospital wide.
+ Experience in clinical outcomes and effectiveness initiatives including review of hospital performance, comparison to standards/norms/targets, and development and implementation of programs to improve outcomes.
+ Demonstrates experience in Small and large group presentations.
+ Knowledge of Lean methodologies.
+ Demonstrates experience in Quality management and performance improvement.
+ Demonstrates experience in Risk management.
+ Demonstrates experience in Compliance.
**EXPERIENCE PREFERRED** :
+ Oversight of, or active participation with medical staff office duties preferred.
**SKILLS AND KNOWLEDGE:**
+ Federal and state licensing regulations and accreditation standards.
+ Knowledge of comparative data bases and public reporting requirements.
+ Versed in hospital and medical staff organization and structure.
+ Fluent in medical terminology to include diagnostic and operative procedures.
+ Knowledge of adult education principles.
+ Personnel management.
+ Fiscal management & resource allocation.
+ Environmental management.
+ Staff development.
+ Proficiency with computer programs, word processing, databases and spreadsheets.
+ Excellent problem-solving skills.
+ Ability to apply critical thinking skills and adapt to a variety of situations with appropriate action.
+ Ability to plan, organize and communicate a team approach to performance improvements in patient care and services.
+ Ability to communicate (orally and written) effectively with diverse range of others, including but not limited to, colleagues, managers, medical staff, patients/family, volunteers and community members.
+ Ability to conceptualize/implement designs, timelines and action plans.
+ Ability to adapt to fast paced work, variable workload, and variable work hours during survey/project implementation.
**Organization:** Sutter Center for Psychiatry
**Employee Status:** Regular
**Position Status:** Exempt
**Job Shift:** Day
**Shift Hours:** 8 Hour Shift
**Days of the Week Scheduled:** Monday-Friday
**Weekend Requirements:** Other
**Schedule:** Full Time
**Hrs Per 2wk Pay Period:** 80
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.
Sutter Health values and supports the unique talents and strengths that each employee brings to our organization. As a result, you are empowered to apply your passion for healing in innovative ways to care for patients and their families.
Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you – and excellent, personalized care for all those we serve.