Manager Quality
: Job Details :

Description

Introduction

Last year our HCA Healthcare colleagues invested over 156,000 hours volunteering in our communities. As a Manager Quality with Terre Haute Regional Hospital you can be a part of an organization that is devoted to giving back!

Benefits

Terre Haute Regional Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
• Free counseling services and resources for emotional, physical and financial wellbeing
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock
• Family support through fertility and family building benefits with Progyny and adoption assistance.
• Referral services for child, elder and pet care, home and auto repair, event planning and more
• Consumer discounts through Abenity and Consumer Discounts
• Retirement readiness, rollover assistance services and preferred banking partnerships
• Education assistance (tuition, student loan, certification support, dependent scholarships)
• Colleague recognition program
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

Would you like to unlock your potential with a leading healthcare provider dedicated to the growth and development of our colleagues? Join the Terre Haute Regional Hospital family! We will give you the tools and resources you need to succeed in our organization. We are looking for an enthusiastic Manager Quality to help us reach our goals. Unlock your potential!

Job Summary and Qualifications

The Manager has responsibility and authority to assist the VP of Quality to plan, organize, and direct the activities and functions of the Quality Resource Management Department. Will share in the responsibility with the VP of Quality for selection, management and evaluation of personnel in the departments.

Responsible for the leadership and coordination of all Core Measures/eMeasure/Registry activities.

Monitors ORYX data from TJC and develops action plans for opportunities for improvement

Responsible for oversight of the QRM Administrative Assistant, MSS Coordinator/Lead, PI Coordinators, Quality Coordinator, Cardiac Coordinator, Stroke Coordinator, and Sepsis Coordinator. As needed, contributes as back-up/trainer to each role.

Maintains oversight of the CMS HARP Program. Works closely with Division/Corporate to meet data deadlines for the hospital and HCA.

Assists the VP of Quality in providing the administrative and technical formal and informal direction to ensure the Quality Management activities are in compliance with ISDH, CMS, The Joint Commission, and other regulatory guidelines

Keeps appraised of changes in regulations as they relate to the Quality Management Program

Coordinates The Joint Commission accreditation activities. Informs Leadership on a regular basis changes and standard compliance of needs in order to maintain survey readiness at all times Performs regulatory compliance monitoring for all regulatory bodies as needed.

Works in coordination with VP Quality to facilitate annual TJC Intra Cycle Monitoring survey, Continuous Readiness Survey Evaluation Survey(CSRE), ISDH Surveys, The Joint Commission Triennial Survey.

Serves as the Quality Coordinator for the facility Commission on Cancer Committee

Coordinates data collection and provides oversight for data in the Quality Dashboard and for the quarterly facility MEC/BOT scorecard on quality metrics for every hospital department or service line.

Ensures all clinical setting contracts have QA reported up to MEC/BOT

Oversees review, compilation, and aggregation of hospital restraint and seclusion rates

Creates, compiles and revises the annual list of contracted services and how their quality metrics are reported up through MEC/BOT

Creates, compiles and revises the annual Physician Education Module.

Completes Joint Commission required Failure Mode Effect Analysis every 18 months per Joint Commission guidelines

Receives and reviews minutes of Medical Staff and hospital-wide Committees to gather information pertinent to Quality Management activities.

Assists as a liaison for various committees and departments to help maintain communication between committees/departments monitoring activities.

Assists Medical Staff with the establishment and maintenance of ongoing monitoring and evaluation activities.

Completes an annual reappraisal of the Performance Improvement Plan/Patient Safety Plan to include a list of summary of relevant findings, actions required to either improve or assure the coordination and integration of PI activities.

Maintains open communication with all other team leaders, administration, and Medical Staff and updates them on any Quality Resource Management and Medical Staff Services concerns/issues

Completes the Hospital Annual Leapfrog Report and submits updates as appropriate for the annual report and the biannual grade release. Proactively works with appropriate staff to maintain the hospitals active participation with Leapfrogs Quality of Care and Safety initiatives.

Completes the Anthem data entries annually (or as instructed by Anthem)

Oversees the hospitals certification programs for TJC: Primary Stroke, and Acute Heart Attack Ready (AHAR)

Performs as a facilitator for Serious Event Analyses on Sentinel Events and Near Misses. Assists directors/managers with an action plan for necessary changes of processes

Participates in interviews, hires, trains, supervises, and evaluates the performance of the employees according to the criteria of their job description

Counsels, disciplines and terminates departmental employees in consultation with the Human Resources Director and Administration

Reviews weekly Plus staffing data in a timely manner

Assists the VP of Quality in assuring that departmental policies and procedures are in place and revised/reviewed and updated tri-annually and as needed

Assists the VP of Quality with regular unit meetings with employees for purpose of communication, problem solving and evaluation of departments operations. Collaborates with staff to establish, implement and evaluate departments goals and objectives

Completes Kronos time sheets weekly and on Payroll Monday

Assists in determining staff development needs and in maintaining competence in field through in-service, outside workshops, and/or selected reading materials.

Maintains strict confidentiality regarding patient, employee and strategic hospital information

Attends monthly management meetings on time and participates as a team member

Attend Code of Conduct training course annually

Demonstrate an understanding of and adherence to HCAs Code of Conduct

Demonstrates conduct that is reflective of THRHs commitment to HCAs Code of Conduct

Understands and satisfies the needs of the patient population appropriate to the age of the patient served (adults, geriatric, adolescent, pediatric, and parents of neonates)

Adheres to the Standards of Behavior for Terre Haute Regional Hospital as per the Customer Relations Policy

Education & Experience:

Above average communication skills in all forms

Graduate of an approved school of nursing

Licensed Registered Nurse in the State of Indiana

BSN or higher required.

Must have comprehensive knowledge of nursing theory and practice.

Three to five years of clinical nursing experience with previous managerial or leadership experience required.

Prior experience in utilization/quality review and/or PRO review required or equivalent experience in nursing filed.

Experience with TJC and ISDH standards required.

Terre Haute Regional Hospital has provided quality healthcare services since 1882. We give patient's access to trained physicians and advanced technology. Our 275+ bed hospital is a leading acute care facilities in Indiana. Terre Haute is the only full-service hospital in the area accredited by The Joint Commission. We have provided quality care to the Wabash Valley community for 135 years. Services include the regions only Level-II trauma center, cardiovascular services--including open-heart surgery and cardiac catheterization; oncology services, which include radiation therapy and outpatient infusion; labor and delivery, including a neonatal intensive care unit; an inpatient behavioral health unit; and other specialized inpatient areas, including intensive care and inpatient rehabilitation units.

At Terre Haute Regional Hospital, our care like family culture extends to our patients, people and our community. We are committed to each other. When we join together, our patients are cared for in the safest and most compassionate way.

HCA Healthcare has been recognized as one of the Worlds Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

There is so much good to do in the world and so many different ways to do it. - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder

Be a part of an organization that invests in you! We are reviewing applications for our Manager Quality opening. Qualified candidates will be contacted for interviews. Submit your application and help us raise the bar in patient care!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.