About Us:
At Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests and treatments, it is about really caring for people with dignity and respect. That's what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.
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 lead 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 datadriven 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 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 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 decile 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 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 multi-disciplinary 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, master's degree preferred.
- Three years of related healthcare experience required.
- Experience using Lean, Six Sigma, or other performance improvement methodology.
- Experience with peer review, mortality review, and chart abstraction for publicly report quality measures.
- Clinical experience preferred.
Knowledge and Skills:
- Effective communication, interpersonal, organizational and facilitation skills.
- Proficient computer skills with extensive experience using various software application 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 required within two years of employment.
Workplace Conditions:
PHYSICAL DEMANDS:
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; and talk or hear
- The employee frequently is required to walk and stoop, kneel, crouch
- The employee is occasionally required to stand
- The employee must occasionally lift and/or move up to 25 pounds.
- Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus
WORK ENVIRONMENT:
- General office environment and the noise level in the work environment is usually moderate
BLOOD-BORNE PATHOGEN EXPOSURE CATEGORY:
xCategory 1 - Job usually involves contact with patients or patient's specimens. Exposure to blood, body
fluids, non-intact skin or tissue specimens, is possible
Category 2 - Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens
Category 3 - Job does not involve exposure to blood, body fluids, non-intact skin or tissue specimens.
Incumbent does not perform or help in emergency medical care or first aid as a part of his/her job.
Benefits:
Sinai Health System's goal is to provide you with the most comprehensive benefit package possible while balancing our fiscal commitments and obligations. Sinai Health Systems currently offers its employees the option to participate in a full range of benefits, including a health care program which includes medical, dental, vision and prescription coverage. Along with Employer Paid Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term and Long-Term Disability, Health Savings Account (HSA) and Flexible Spending Account (FSA), Employee Assistance Program and Student Loan Assistance. Participation in some programs
requires that employees be regularly scheduled to work a minimum number of hours and/or to have fulfilled a waiting period after they begin employment with Sinai Health Systems.
Registry (per diem) Caregivers are caregivers who work less than 1,000 hours in a calendar year. Registry caregivers are employees of Sinai Health System but are typically on an as needed basis. These caregivers may be called upon to cover full-time or part-time caregivers during PTO events or sick leave as well as to provide supplemental coverage. Registry Caregivers are not eligible for Sinai's benefit programs with the exception for Sick-C, PPO Medical Plan, Employee Assistance Program (EAP) and non-match eligible contribution to the Sinai Health System Consolidated 403(b) retirement savings plan.
Living the Values:
- TEAMWORK - Caregiver works together with other caregivers to create and maintain an inclusive
- workplace where differences, inclusivity, conflict resolution and open communication are valued
- RESPECT - Caregiver shows mutual respect and fairness, treats each person with dignity and
- QUALITY - Caregiver improves our services by following protocol and suggesting improvements based on observations, continuous learning and industry best practices
- INTEGRITY - Caregiver holds self and others accountable for their actions and are honest and ethical in all dealings
- SAFETY - Caregiver practices behaviors that promote safety for all patients, visitors, and caregivers
- ROLE MODEL - Caregiver is a dependable role model and champions our values through their daily interactions with patients, customers and coworkers