POSITION SUMMARY
The Clinical Quality Manager plans and directs the operational, budgetary and personnel activities of the quality department to ensure alignment with organizational objectives. This requires a wide range of concepts, principles, and practices in the healthcare profession, and the manager must apply knowledge and skills to the development of new methods and approaches using performance improvement principles. The manager ensures improvement opportunities are prioritized based on their occurrence and expected impact on patient outcomes. The manager must possess the ability to interpret and display organizational data at the executive level to promote decision making that supports quality and regulatory requirements. The manager is responsible for regular interactions with executive level individuals to create change within the organization. The Clinical Quality Manager must be able to partner with the regulatory and information technology departments to support organizational goals to achieve and maintain accreditation. The manager is responsible for quality management, system development, and implementation of quality reviews. The manager will coordinate a variety of activities, quality reviews and reports, to ensure a state of readiness and progress. The incumbent holds staff accountable to preparedness of data and outcomes. Implements strategies to ensure compliance with all applicable regulatory requirements and makes recommendations regarding activities to support strategies. The manager is responsible for continual performance improvement, education/training and reporting of the leadership and staff quality reviews.

MAJOR POSITION RESPONSIBILITIES
The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.
1. Maintains a safe, clean working environment, including unit based safety and infection control requirements.
2. Promote and support systems and processes to achieve high quality, safe, cost effective healthcare.
3. Develop/coordinate effective measurement, analysis, interpretation and reporting of patient care and service processes and outcomes.
4. Facilitate the identification of specific organizational quality management/performance improvement needs and opportunities.
5. Identify concerning trends in data (surveillance) and engage an appropriate corrective response.
6. Collaborate with information technology to assist in the development of systems to support collection and distribution of quality data for improvement of patient outcomes.
7. Lead/Facilitate appropriate quality committees to ensure organizational data/information flow through organizational committee structure.
8. Facilitate meetings to assess performance improvement targets and address any anticipated deficiencies.
9. Prepare regulatory reports for external agencies and presentations to the Board of Directors, Executive Council, Directors, and Medical Staff.    
10. Participate in organization wide communication of the development, implementation, and ongoing evaluation of the effectiveness of the quality strategy.
11. Align the organization through strategic quality planning and the development of annual quality initiatives to build a top-level set of performance measures for internal reporting to ensure accurate display of organization wide data within a balanced scorecard.
12. Assure compliance with regulatory data expectations, initiatives, and performance improvement requirements.
13. Facilitate quality of care reviews with physicians, nurses and disciplines to investigate care and system issues.
14. Facilitate timely and expeditious data filing to meet deadlines.
15. Perform applicable annual employee performance reviews.  Develop and conduct effective training programs on related quality topics.
16. Participate in continuous improvement activity in support of continual improvement initiatives.

QUALIFICATIONS
– Minimum of five (5) years of clinical healthcare experience, required.
– Minimum of five (5) years in healthcare quality improvement, required. 
– Prior management experience, required.
– Experience with hospital regulatory accreditation, preferred. 
– Must be dependable, have integrity, initiative, tact, ability to work on details, ability to learn and possess a sense of values and ethical standards, required. 
– Must also have the ability to train and develop other personnel by providing them with the knowledge gained through years of experience on the job, required. 
– Possess knowledge of the business of health care along the continuum of care, clinical decision support data analysis/syntheses and quality improvement, regulatory and legislative issues, required.

EDUCATION
– Bachelor’s degree in nursing, or health related field or information systems, required.
– Master’s degree in nursing or health related field from an accredited university, preferred. 
– Master’s degree in information systems or management, preferred.

LICENSES
– Current RN California license, preferred.

CERTIFICATIONS
– Certified Professional in Healthcare Quality (CPHQ), required.

About the Hospital:
Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community.

Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class women’s health, robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. The hospital operates a Level III Neonatal Intensive Care Unit (NICU). Tri-City partners with over 50 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs.

Our facilities include a hospital at 4002 Vista Way in Oceanside, nearby outpatient services, an orthopedic, primary care and urology clinics.