Title: Clinical Quality Improvement Manager

FLSA Status: Full time Employee/Exempt

Reports to: Director, Quality Improvement and Patient Safety

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Colorado Hospital Association (CHA) is the leading voice of Colorado’s hospital and health system community. Representing more than 100 hospitals and health systems throughout the state, CHA serves as a trusted, credible and reliable resource on health issues, hospital data and trends for its members, media, policymakers and the general public. Through CHA, Colorado’s hospitals and health systems work together in their shared commitment to improve health and health care in Colorado.

The CHA Quality Improvement and Patient Safety Department works with the Association’s members to advance the adoption of evidence-based strategies that improve the reliability, safety and quality of care. The team collaborates closely with the quality and patient safety departments in member hospitals and health systems on a variety of quality improvement initiatives. Current work includes implementing alternative to opioids protocols in hospital emergency departments; raising awareness for the early detection and treatment of sepsis; reducing readmissions; developing and sustaining patient and family advisory councils; and more.

Summary:

The Clinical Quality Improvement Manager is primarily responsible for coordinating and managing various clinical aspects of quality and patient safety initiatives in which CHA engages and serves as a clinical resource within CHA and to member hospitals and health systems. The Clinical Quality Improvement Manager actively promotes a culture of patient safety, proactive risk management, clinical excellence, and on-going regulatory readiness.  This position is supervised by the Director for Quality Improvement and Patient Safety, who will provide ongoing assistance and support in helping the Clinical Quality Improvement Manager carry out the duties of the position.

The CHA Quality Improvement and Patient Safety Department works with the Association’s members to advance the adoption of evidence-based strategies that improve the reliability, safety and quality of care. The team collaborates closely with the quality and patient safety departments in member hospitals and health systems on a variety of quality improvement initiatives. Current work includes implementing alternative to opioids protocols in hospital emergency departments; raising awareness for the early detection and treatment of sepsis; reducing readmissions; developing and sustaining patient and family advisory councils; and more.

Essential Job Duties and Responsibilities:

The Clinical Quality Improvement Manager will be responsible for coordinating the activities of assigned quality and patient safety projects and training programs. These include but are not limited to:

• Assist CHA member hospitals and health systems with preparation and implementation of performance improvement initiatives
• Oversee quality and patient safety related projects using project management methodologies to achieve project deliverables
• Work with CHA members to design and implement evidenced based practices to address quality and patient care issues
• Support CHA members to improve patient care with the design, implementation and evaluation of patient specific and population based programs across continuum of care.
• Plan and coordinate education campaigns in coordination with internal and external parties
• Educate, communicate, and promote key quality improvement and patient safety principles including Hospital Quality Incentive Payment Program, Joint Commission, National Patient Safety Goals, and Value Based Purchasing
• Support clinical quality data collection and analysis as required by law, regulation and quality improvement
• Partner with other healthcare organizations, such as Telligen, CIVHC and CDPHE, to support CHA goals and objectives
• Produce and communicate project progress using actionable clinical data. Information to be presented to Quality & Patient Safety Director and other internal/external customers
• Serve as a leader/mentor/change agent/consultant in advancing patient safety across the care continuum (including the practice of nursing) to improve quality, reduce medical errors and adverse events and maximize patient safety and value
• Conduct site visits to member hospitals throughout the state in support of performance improvement initiatives, at a hospital’s request, or to welcome new members
• Maintain an awareness of legislative and regulatory activities related to patient safety and health care risk management; collaborate with CHA legislative and regulatory staff
• Ensure CHA website content is up-to-date for assigned areas of responsibility
• Pursue grant and other funding opportunities to include writing grant proposals and applying for funding
• Assist other team members as needed
• Assume other relevant assignments or responsibilities as requested by the Director, Quality Improvement and Patient Safety

Knowledge and Experience Required:

• Clinical bachelor’s degree (e.g., RN, PharmD, RPh, RRT) from an accredited college or University required
• Graduate degree (Masters or Doctorate) preferred
• Minimum two years’ clinical experience in a hospital setting
• Minimum two years’ experience in quality improvement/patient safety in a hospital setting preferred
• CPHQ Certification preferred
• Performance Improvement experience/certification preferred (LEAN, Kaizen, Six Sigma)
• Project Management experience/certification preferred (CAPM, PMP)
• Strong clinical and healthcare industry knowledge
• Understanding of relevant patient safety sciences including but not limited to culture of safety, accident causation, and human factors engineering

Skills and Competencies:

• Ability to inspire trust and be known as someone who provides support and assistance
• Strong attention to detail and accuracy
• Demonstrated customer service orientation, approachable with positive attitude
• Demonstrated organizational skills
• Ability to relate and communicate positively, effectively and professionally with others
• Ability to lead, organize and execute projects
• Excellent written and verbal communication skills
• Strong data analytic skills, including ability to present clinical, quantitative and qualitative data effectively
• Ability to work well under pressure and within short deadlines while managing multiple priorities
• Analytical problem-solving ability
• Ability to handle sensitive situations with tact and diplomacy
• Ability to handle confidential information and situations discreetly and professionally
• Ability to work independently with limited supervision and to complete tasks on time
• Professional telephone and email etiquette, professional appearance and demeanor, able to interact with all levels within the organization
• Self-starter with a strong desire to learn
• Maintains prompt and regular attendance

Physical Demands / Work Environment:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Working conditions are normal for a fast-paced office work environment
• Presentation of technical material in group settings required occasionally
• May require occasional evening work and overnight travel
• Some local travel required, as such a valid drivers’ license is required
• Mid-level stress
• Individuals may need to sit or stand as needed
• Requires walking primarily on a level surface for periodic periods throughout the day
• May include lifting up to 25 pounds for files on a regular basis. Proper lifting techniques required

Material and Equipment Directly Used:

• Personal computer with Microsoft Office and other software applications
• Software applications including but not limited to database management, data analytics, project management and presentation tools
• Facsimile
• Cell phone
• Multi-line telephone with voice mail
• Copy machine
• Printer

NOTE: This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the job. The employee will be required to follow any other instructions and to perform any other duties requested by their supervisor. Nothing in this job description shall create or is intended to create, or shall be construed to constitute a contract of employment, express or implied. Employees are held accountable for all duties of this job.