Manager of Quality Improvement

Care New England Health System; Warwick; On-site; GBP 40,000 - 70,000

Job description

The Providence Center Manager of Quality Improvement (QI) is responsible for developing, monitoring, and presenting quality improvement initiatives, coordinating QI teams, and providing education on clinical documentation and processes. This includes reviewing patient and staff safety events, preparing reports for internal and external audiences, and ensuring regulatory compliance. The Manager also acts as the Human Rights Officer, leads utilization management efforts, supports incident report reviews, and assists with licensing and accreditation preparation.

The Manager will present an overview of compliance and quality improvement practices during new employee orientation.

This role requires strong analytical skills, the ability to collaborate with leadership, and a focus on continuous improvement and fostering a culture of safety and excellence.

Duties and Responsibilities

Primary responsibilities include conducting quality assurance checks, reviewing and analyzing patient and staff safety events using an electronic reporting system, and preparing summary reports on quality data for internal and external audiences.

The Manager will support and coordinate various quality improvement teams and committees, serve as a resource to leadership, and participate in staff training and orientation.

The Manager acts as the Human Rights Officer (HRO) to advocate for individuals receiving services, conduct investigations, and ensure that clinical documentation meets regulatory requirements.

The position also involves leading utilization management efforts, assisting with incident report reviews, supporting licensing and accreditation preparation, and collaborating with staff and leadership to drive compliance and continuous improvement in clinical practices.

Other duties as assigned.

Quality Improvement (QI)

Assists in the development, monitoring, and presentation of internal quality measures and initiatives.

Assists with supporting, coordinating, and directing quality improvement teams.

Supports clinical teams in planning improvement activities utilizing standardized improvement methodologies.

Prepare reports to appropriate committees on processes for improvement, trends, and actions identified through the QI program and processes.

Lead center-wide efforts to educate staff regarding quality improvement trends, benchmarks, and developments.

Reviews QI tools and surveys and provides technical assistance to staff.

Participate in staff and management meetings as they relate to Quality Improvement activities.

Prepare summary reports of quality data and improvement activities for presentation to internal and external audiences.

Support Quality Improvement teams and committees.

Serve on standing and ad-hoc committees and teams.

Training and Education

Provide ongoing clinical education and training to staff on documentation and processes.

Conduct new staff hire orientation.

Ensure that clinical staff are provided ongoing training on the reporting requirements of regulatory bodies, third-party payors, and managed care companies.

Lead center-wide efforts to educate staff regarding quality improvement trends, benchmarks, and developments.

Provide an overview of compliance, quality improvement practices, and clinical documentation standards during new employee orientation to ensure all staff understand key policies, procedures, and expectations from the outset.

Documentation and Quality Assurance

Performs quality assurance checks of documentation workflows and clinical data.

Provides the Director and Center management with reports on clinical quality record reviews.

Ensure that medical records are clinically relevant and appropriate and that they meet the requirements established by funding sources and managed care companies.

Ensure that ongoing medical record reviews are performed as necessary to monitor the quality of medical records documentation.

Use electronic event reporting system to review trends and analyze patient and staff safety events.

Perform analyses of select patient safety events.

Human Rights Advocacy (HRO) Role

Act as the Human Rights Officer (HRO) per BHDDH guidelines providing advocacy for all persons served while working cooperatively and effectively with the Center staff.

Serve as an advocate for all persons receiving treatment and services while working cooperatively and effectively with staff.

Conduct investigations.

Perform responsibilities in an impartial manner.

Conduct and submit written reports on the results of any investigations.

Supervises additional staff trained as Human Rights Officers.

Lead the operation and maintenance of The Center's Utilization Management efforts.

Licensing, Accreditation, and Incident Reporting

Assist Director with preparing for licensing and accreditation visits.

Assist with Incident Report review. Attend and participate in all case reviews/root cause analysis.

Assist in reporting to licensing and accreditation any critical incidents and subsequent case reviews.

Act as a resource to leadership and committees to facilitate compliance with various regulatory and accrediting agency requirements.

Requirements

Minimum of three years’ experience in Performance management activities required.

Bachelor's degree required, master’s degree preferred in Human Services, Social Work, Psychology, Nursing, or related field.

Relevant experience in Performance improvement setting with knowledge of State Regulations and CARF standards.

Knowledge of quality improvement methodologies such as FOCUS-PDCA preferred but not required. Demonstrated competence in record keeping.

Proficiency in using electronic health record (EHR) systems and event reporting software.

Proficiency in Microsoft applications including Word, Excel, Access, Outlook, and internet required. SPSS preferred but not required.

Strong analytical skills, with the ability to assess and interpret data trends for quality improvement.

Knowledge of clinical documentation standards and regulatory reporting requirements.

Excellent written and verbal communication skills for presenting quality data and educating staff.

Ability to collaborate with multidisciplinary teams and serve as a resource for leadership and committees.

Strong problem-solving abilities and attention to detail.

Strong team player with excellent verbal and written communication skills needed.

Self-directed individual with the ability to prioritize multiple tasks, focus on detail, meet deadlines and maintain a high level of work quality.

Must be organized and enjoy directing clinical improvement teams.

Must have valid driver's license and insured auto.