RN Manager, ASC Quality

RN Manager, ASC Quality

The Manager, ASC Quality is critical in ensuring the highest standards of quality and patient safety across our network of surgery centers. The ideal candidate will possess a deep understanding of AAAHC standards, CMS regulations, and IDPH guidelines, and will be able to effectively collaborate with ASC Clinical Managers, Risk Managers, and ASC Directors to develop and implement robust quality improvement initiatives.

Leadership Philosophy: We believe that leadership is a privilege, one that carries the responsibility to inspire out teams to achieve the vision, how respect for those we serve, and coach our teams and individuals for growth and development. We place our people first and respect their inherent knowledge and talents by empowering them to share their ideas and make decisions that achieve high quality care and service to the patients we serve.

Primary Duties and Responsibilities:

• AAAHC Accreditation: Oversees and manages the AAAHC accreditation process for assigned surgery centers, ensuring compliance with all standards and regulations.
• Conducts regular reviews of policies and procedures to maintain compliance and identify areas for improvement.
• Prepares for and participates in AAAHC surveys, addressing any deficiencies or non-compliance issues.
• Quality Improvement: Collaborates with ASC Clinical Managers to develop and implement comprehensive quality improvement plans.
• Analyzes quality data and identifies trends to inform improvement strategies.
• Develops and conducts educational programs for staff to enhance knowledge and skills related to quality and patient safety.
• Monitors and tracks key performance indicators (KPIs) to measure the effectiveness of quality initiatives.
• Risk Management: Works closely with Risk Managers to identify and mitigate potential risks.
• Conducts root cause analyses of adverse events and implements corrective action plans.
• Develops and implements strategies to reduce medical errors and improve patient outcomes.
• Regulatory Compliance: Ensures compliance with all applicable federal, state, and local regulations, including CMS, IDPH, and AAAHC standards.
• Stays updated on regulatory changes and communicates changes to relevant staff.
• Conducts regular audits to identify and address compliance gaps.
• Clinical Support: Provides clinical expertise and support to ASC staff as needed.
• Participates in performance improvement activities and patient safety initiatives.
• Collaborates with other healthcare professionals to ensure seamless patient care.
• Preadmission Team Management and Compliance: Fosters and environment that promotes staff growth and development along with maintaining a positive proactive view about processes of the surgery center.
• Recruits and screens applicants for clinical personnel for hire and oversees training plans to facilitate a positive new hire onboarding experience.
• Orients new personnel, maintains clinical employee records. Performs regular written employee evaluations.
• Develops team by providing training opportunities, ongoing coaching, and performance feedback and management, aligning team goals and accountability with organization initiatives and service standards.
• Ensures accurate and timely screening and education of patients prior to surgery within the preadmission team.
• Develops and implements policies and procedures for preadmission screening and education, including the collection of necessary medical history and social determinants of health information.
• Collaborates with the county health department to stay informed of community health trends and guidelines.
• Monitors and analyzes preadmission data to identify trends and areas for improvement.
• Develops and implements strategies to improve patient engagement and adherence to pre-operative instructions.
• Assumes all other responsibility as necessary

Competencies: Leadership, People Development and Management, Communications and Interpersonal Relations, Business and Project Management, Service, Continuous Improvement

Organizational Culture: All OrthoIllinois employees focus on service by putting the mission, vision, and value statements into practice and using the guiding principles of Compassion, Respect, Trust, Integrity, Innovation, Education Fiscal Responsibility, Practice Independence, Accountability, and Empowerment to direct their interactions and decision making. Employees promote and model the service standards to create lasting impressions, extraordinary moments, exceptional on-stage experiences, and meaningful and compassionate connections.

Education and Experience Requirements: Registered Nurse (RN) licensure in good standing, Bachelor's degree or Master's degree in Nursing or Healthcare Administration preferred. Minimum of 5 years of experience in an ambulatory surgery center or hospital setting preferred. Strong knowledge of AAAHC or Joint Commission standards, CMS regulations, and IDPH guidelines preferred. Experience with quality improvement methodologies and data analysis preferred. Certification in Quality Improvement or Risk Management preferred. Experience with electronic health records (EHRs) preferred as well as knowledge of surgical procedures and perioperative nursing.

Environmental/Working Conditions: Working environment is in an office, clinic and/or operating room setting. May have exposure to biohazard materials such as blood, body fluids, ionizing radiation, and other conditions common to the operating room environment.

Physical/Mental Demands: Sit, stand, walk, stoop or kneel, crouch or crawl, and climb stairs for long periods of time. Requires lifting, carrying and/or moving objects in a manner consistent with most office environments (generally, no more than 10 pounds on a frequent basis and 20 pounds on an occasional basis). Possess full range of motion in shoulders and arms, including reaching above or below the shoulder. Finger dexterity; the ability to twist hands/wrists repetitively. Vision (e.g., depth perception, color vision, strong vision up close), hearing (e.g., high pitch sounds, soft or distant sounds)

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.