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Sutter Health Manager, Quality & Patient Safety (Acute Clinician) in Modesto, California

Organization:

MMC-Memorial Medical Center

Position Overview:

Sutter Memorial Medical Center strives to provide high quality, compassionate care to each patient, while exercising prudent fiscal responsibility.

Sutter Memorial Medical Center is a community based and not-for-profit organization that exists to maintain and improve the health status of the citizens of greater Stanislaus County. We extend selected services to other communities whenever this will meet the critical needs and when it will enhance the productivity of local resources.

We pursue our mission by providing and promoting effective health care services and by fostering an integrated system of care in partnership with physicians, other health care providers, and payers. We provide access to a full continuum of care, built upon a core of sophisticated hospital-based services.

Responsible and accountable for facilitating, measuring, evaluating and reporting on the clinical and operational performance of system-wide patient safety and clinical quality initiatives. These initiatives may include, but are not limited to, The Joint Commission (TJC), Center for Medicare Services (CMS), Quality Net (QNet), Leapfrog, National Patient Safety Foundation (NPSF), National Healthcare Safety Network (NHSN) for Acute facilities and Institute for Medical Quality (IMQ) and Integrated Healthcare Association (IHA) for Ambulatory facilities as well as initiatives driven internally and obtained through various data sources as applicable.

Responsible for the effective management of staff including hiring, performance evaluations, employee growth and development, satisfaction and as needed counseling and disciplinary actions. Coordinates and participates in the planning, data collection, data analysis, implementation and follow up for multifaceted quality performance assessment and improvement projects for affiliate. Develops protocols for the collection of data and designing data collection instruments. Collaborates with the abstraction and analytic team to compile and analyze results; composes status reports on analyses. Designs and delivers presentations of material developed. Manages project budget and timelines. May manage chart abstraction staff. Functions as project leader and manager. Works on performance-measurement, target-definition, evaluation and reporting expertise necessary to drive significant breakthroughs related to patient safety, risk reduction, and clinical quality and care management performance. Responsible for independent action in performance measurement metrics and a variety of special projects. Participates in evaluations of current information processing systems and coordinates planned changes, upgrades, and conversions as appropriate. Collaborates with personnel responsible for EMR, internal reporting platforms, and Sutter Information Services as well as other available databases to measure performance. Continually facilitates management and clinical leaderships' ability to monitor and review relevant and focused results to include customer input, reimbursement, patient safety, clinical quality, and regulatory compliance.

Job Description :

EDUCATION:

Equivalent experience will be accepted in lieu of the required degree or diploma.

Bachelor's

CERTIFICATION & LICENSURE:

  • RN-Registered Nurse of California

  • OR MD-Medical Doctor

  • OR PharmD-Pharmacist

  • OR PA-Physician Assistant

  • ​OR NP-Nurse Practitioner

TYPICAL EXPERIENCE:

  • 8 years recent relevant experience.

JOB ACCOUNTABILITIES:

Provide Business Intelligence Solutions:

Develop, maintain and distribute data reports, scorecards, and dashboards while implementing advanced optimizations for quicker turn-around.

Consult with customers and vendors to identify and resolve advanced problems, following through to ensure final resolution.

Perform expert analysis on the existing reports prior to distribution to highlight changes in trends or variations.

Areas of report responsibility may include but are not limited to: Quality and Patient Safety, Comprehensive Health Assessment and Infection Control.

Perform Data Analysis:

Elicit requirements from end-users in support of quality and safety initiatives. Lead improvement projects/programs as appropriate.

Perform advanced analysis on the existing reports prior to distribution to highlight changes in trends or variations.

Utilize advanced understanding of statistical concepts to present or display data in a way that is end user focused and accessible.

Perform advanced level extraction and aggregation from various data sources to highlight trends and gaps in care.

Prioritize multiple defined projects or tasks to ensure on-time completion.

Support and Maintain Applications and Databases

Troubleshoot advanced issues within database applications and modify existing dictionaries or settings based on changing requirements.

Ability to perform data quality, data maintenance, and access provision with internal and external database applications as applicable to the ambulatory versus hospital setting.

Develop and maintain a record of data collection methods, database structure, code and analyses that is accurate, reliable and accessible.

Review and manage various system log files, error reports, alert audit logs, and security access logs, as assigned.

Communicate key issues or incidents on a regular basis to immediate supervisor.

Process Improvement:

Work collaboratively with key stakeholders inside and external to the Quality and Safety Department to design and conduct performance improvement and outcomes studies.

Utilize working knowledge of applications to drive process improvement and reduce waste through use of standard work such as checklists and workflows.

Maintain up-to-date knowledge of improvements and upgrades in relevant applications, SQL and other appropriate programming language.

Develop an expert knowledge of application databases, desktop configuration, and application configuration for effective participation in all phases of project implementation and application support.

Operational and Leadership Responsibilities:

Monitors the resources utilized for projects and
reports regularly to the Director.

Fiscal management of team resources are compliant with budgetary guidelines.

Manages, coordinates and assesses the day-to-day operation of the quality and safety improvement projects.

Manages the planning of the projects including establishing goals and objectives, training requirements, productivity goals and financial parameters.

Coordinates and conducts regular meetings with project collaborators and affiliate/operating unit/system leadership to ensure that the goals and
objectives are being met.

Ensures the adherence to policies and procedures established by the affiliate, operating unit, and system, federal and state government, and outside agencies.

Ensures compliance with HIPAA rules and regulations.

Ensures adherence to department procedures that protect patient confidentiality, private health information, and Sutter Health proprietary information.

Human Resource Management:

Leads by example. Clearly communicates to staff achievable goals and steps required to achieve them.

Conducts performance reviews, mentors and encourages staff growth and development.

Responsible for hiring, counseling and disciplinary action as needed.

Documents and evaluates attainment of personal performance goals that are relevant, measurable and achievable.

Identifies areas of further professional development and participates in activities which promote this growth.

Collaborates with the Quality and Patient Safety Director to enrich personal/professional development as it relates to unit operations.

SKILLS AND KNOWLEDGE:

Knowledge of database architecture and management and data extraction methods required.

In-depth experience with Midas, including Quality, Risk and Case Management modules, and/or Epic EHR, or the equivalent.

Experience with Statit PPR, Statit PiMD, Tableau, Crystal Report Writer and/or Allscripts or the equivalent.

Advanced SQL knowledge and experience

Advanced skill with presentations, word processing and spreadsheet applications with an advanced knowledge of Microsoft Office Suite required. Must be advanced in MS Excel.

Advanced analytical skills with the ability to collect, analyze, and disseminate significant amounts of information with attention to detail and accuracy. Experience with statistical methodology is required.

Knowledge of health care operations, and health care (International Classification of Diseases (ICD 10), Current Procedure Terminology (CPT) and/or Diagnosis Related Groups (DRG)) coding with a focus on quality management and care coordination services in acute and non-acute outpatient settings. Includes structure, department-specific policies and procedures and workflows.

Requires teamwork, organizational and communication skills. ability to be involved in and prioritize multiple projects at the same time in a rapidly changing environment.

Must have the ability to interact with all levels of employees and medical staff as well as interface directly with external agencies and organizations.

Must have ability to organize, interpret and present data effectively; creatively and effectively problem-solve, good decision-making skills.

Leadership, communication and teaching / training skills.

#LI-FM1

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

As Needed

Benefits:

Yes

Unions:

No

Position Status:

Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

1

This position may regularly work, store, prepare, receive, unpack, transport, dispose of, or administer drug(s) identified as hazardous, or potentially hazardous, by the National Institute for Occupational Safety and Health (NIOSH) for purposes of USP 800.

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $66.58 to $106.53 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.

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