CHRISTUS Health · 8 hours ago
Manager Quality Management-Quality Management-Full Time
Mamou, LA
Full-time
Onsite
Mid Level
3+ years expCHRISTUS Health is seeking a Manager of Quality Management who will oversee compliance with JCAHO standards and federal regulations. The role involves coordinating quality management initiatives, maintaining performance improvement data, and facilitating compliance efforts across the organization.
Hospital & Health Care
Responsibilities
Reviews and Revises hospital wide policies and procedures to follow the standards set forth by CMS and JCAHO
Coordinates the Board’s, Medical Staff’s, and hospital staff’s roles in JCAHO compliance and survey preparation
Provides data and analysis reports to the various organizations; local, division, state and group leaders on an ongoing basis, as appropriate
Maintains Physicians’ awareness of their Quality Management performance on an on-going basis through individual and committee reporting
Provides Performance Improvement leadership and consultative services for hospital and medical staff in effectively achieving regulatory accreditation and organizational compliance for Performance Improvement
Reports Performance Improvement Data for both the hospital and the medical staff departments to identify trends, establish priorities, and recommend Improvement activities
Performs comprehensive concurrent and retrospective review in a timely manner utilizing criteria developed and approved by the medical staff and the hospital
Appropriately reports issues found during record reviews to utilization review, infection control, risk management, and other departments as necessary
Assists departments and the PI Coordinator in determining their quality management collection, reporting and training needs
Assist departments and the PI Coordinator in setting standards for departmental data collection, processing, and reporting internally and externally
Act as a change agent and facilitates the change process, to include data analysis, research and development per the direction of the Chief Executive Officer and/or Governing Board
Maintains current in JCAHO and regulatory compliance issues
Collaborates and integrates Risk Management, Patient Satisfaction, Infection Control, Environment of Care and other hospital wide data into the overall Quality Management program
Collaborates with the Medical Staff Coordinator in the collection and reporting of Physician specific data for credentialing purposes
Assures integration of the 'Patient Safety' program andNational Patient Safety goals with the Quality Management initiative and provides input regarding areas of improvement, as appropriate
Coordinates external database data collection and reporting for comparative analysis with the JCAHO and other entities, as appropriate, based upon Medical Records review and other internal data collection
Provides identification of and recommendation for staff educational needs related to Quality Management, JCAHO and other regulatory agency compliance
Provides recommendations for resolution and changes regarding identified opportunities for organizational improvement
Facilitates the Quality Improvement Teams as necessary
Provides input, as well as appropriate organizational quality resource management information, analysis and recommendations to formulate sound organizational business plans
Serves on the Performance Improvement Council and any other organizational or Medical Staff committees as deemed necessary
Abstract charts for Core Measures and enter into the Quantros system
Work with Healthstream regarding HCAHPS data
Identifies and makes recommendations regarding the software and technological advancements needed to enhance data collection and reporting capabilities to support the organization’s mission statement
Develops and implements policies and procedures for the department
Responsible for the recruitment, interviewing and selection of staff utilizing staffing patterns developed for the department
Responsible for the completion of performance evaluations for all employees in the department. Returns completed evaluations to Human Resources in a timely manner
Recognizes employees’ accomplishments, counsels them when needed, and uses disciplinary process when necessary
Fosters open communications with other departments by attending committees meetings when appointed, and when necessary working on Performance Issues with other departments
Punctuality
Attendance of Hospital mandatory In-services
Compliance with Hospital Safety Policies and Procedures
Establishes good interpersonal and working relationships with co-workers, employees, patients, and public
Respects the rights and privacy of others; holds employee and patient information in confidence
Adheres to HIPPA guidelines
Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
Demonstrates knowledge of the occurrence reporting system. Uses system to report potential patient safety issues
Follows established guidelines for reporting a significant medical error or unanticipated outcome in the patient’s care, which results in patient harm
Attends inservice presentations and completes mandatory education week including, but not limited to infection control, patient safety, quality improvement, MSDS and OSHA standards (PPE, First Aid, blood-borne pathogens, hazard communications, emergency procedures and job safety)
Uses performance improvement plan to improve patient safety
Performs all duties and provides care to patients while adhering to the standards of the Patient Safety Plan and the National Patient Safety goals
Qualification
Required
Associate Degree in Nursing or in a related field required
Three years of healthcare experience
CPHQ (Certified Professional in Healthcare Quality) within 2 years
CPR every two years
Current RN licensure in State of Louisiana
Company
CHRISTUS Health
CHRISTUS Health is a Catholic not-for-profit health care system comprising more than 600 centers, including long-term care facilities, community hospitals, walk-in clinics and health ministries.
10001+ employees
H1B Sponsorship
CHRISTUS Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (43)
2024 (35)
2023 (54)
2022 (46)
2021 (22)
2020 (26)
Funding
Current Stage
Late StageLeadership Team
Terry Kyle
CEO and CDO The Children's Hospital of San Antonio Foundation & Friends of CHRISTUS Santa Rosa Fnd
Thomas Royer, MD
CEO Emeritus
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