UI Health - Administrative Nurse III (Quality Manager) - MSHC

apartment UI Health location_onChicago, IL, US

Position Summary

The Administrative Nurse III (Quality Manager) is a Registered Professional Nurse responsible for leading quality improvement initiatives and ensuring compliance with regulatory standards. This role integrates Relationship-Based Care, Evidence-Based Practice, and Magnet's Five Models of Care to improve patient outcomes. The Quality Manager oversees data collection, analysis, and reporting for quality metrics, facilitates staff development, and drives strategic initiatives aligned with organizational goals.

Duties & Responsibilities

Professional/Leadership

• Establishes and maintains Mile Square performance improvement program

• Collection, management, and analysis of quality data, and the preparation of quality reports.

• Practical knowledge of tools and techniques of Continuous Quality Improvement, including analysis and interpretation of data using computer-based disease registries or similar data collection systems,

• Conducts quality chart audits as needed on topics such as, but not limited to HEDIS measures, UDS measures, PCMH and evidence-based guidelines. • Coordinates preparations for HRSA on site visits

• Develops and implements QI reporting calendar

• Complies and summarizes finding from chart audits with recommendations for quality improvement to the

Director of Quality

• Coordinates periodic patient satisfaction surveys with clinical support teams to enhance change and /or develop clinic services.

• Coordinates periodic staff surveys and complies reports for the CEO, COO and CMO to be used in provider performance assessments.

• Conduct analysis and identify opportunities and action plans for patient satisfaction and staff improvement.

• Proactively monitors quality metrics and identifies opportunities for improvement. interdepartmental staff

• Supports the Director of Quality with QI reports and initiatives to be presented at the monthly provider meeting and QI committee meetings.

• Define, monitor, and execute quality initiatives across all departments within the organization.

• Monitors outcome measures and implementation of implemented QI programs and maintains a log of all QI activities.

• Facilitates process improvement groups as needed.

• Work with Administrative Nurse IIIs as needed on Quality Improvement

• Demonstrates the highest level of customer service to internal and external customers

• Actively participates in Health Center communication processes through timely review and response to electronic and written messages

Performance Metrics

• Achievement of quality benchmarks and compliance standards.

• Improvement in patient satisfaction and clinical outcomes.

• Timely completion of audits, reports, and corrective actions.

• Staff engagement

Organizational

• Adheres to and enforce the Medical /Health Center’s Code of Conduct

• Treats patients/families, staff, students and visitors with respect and dignity

• Adheres to and enforces clinical support staff time, overtime and attendance policies

• Completes electronic learning modules and related programs as assigned by Medical Center Learning by established date

• Complies with University Health Services TB and fit-testing requirements

• Initiates resolution of patient care problems utilizing established communication channels/chain of command

• Resolves recurring clinical practice and/or related unit problems

• Participates in problem solving and resolution utilizing established communication channels/chain of command

• Assists in writing, implementing, managing, and reporting on grants in the QI division

• Facilitates the planning, presenting and evaluating of learning/educational experiences for staff and students

• Serves as resource to clinical staff

• Directs unit-based quality initiatives and provides feedback and education to staff

• Encourages and supports nursing and multidisciplinary research efforts conducted on the unit and in the Health Center

•Responsible for continued professional growth/development by identification of learning needs and initiates strategies to meet such needs

•Assists in the development, monitoring, and presentation of internal quality measures and initiatives

•Coordinating tracking and reporting of clinical outcomes, and follow-up of corrective action plans

•Provides in-service training to non-provider staff in the area of quality improvement

•Prepares QI reports and statistics Strategic Planning and Goal Setting

•Study most recent trends, innovative approaches in the ambulatory health care industry to apply new concepts towards organizational strategic goals

•Manages positive relations with providers to facilitate patient care. Oversees provider productivity and provider scheduling process and work to ensure coverage

•Provides primary input to the executive management team on decisions affecting practice site(s), as well as feedback on department programmatic, planning, and policy issues

•Assist with annual UDS and HRSA reports

•Reviews literature for upcoming HRSA and Illinois regulatory audits; changes and develop strategic plans to implement prospective changes as needed

•Direct and implement disaster management drills for MSHC and participates in UIC campus-wide disaster drills as needed

•Co-manage the implementation of Patient-Centered Medical Home (PCMH), throughout the Mile Square enterprise

•Meet established work/compliance/project deadlines as required

•Responsible for developing methods for data collection and extracts data as required Regulatory Compliance

•Ensure policies and procedures for the practice site(s) are reviewed by staff as required by University, Medical Center, MSHC, and external regulatory agencies, particularly the Health Resources and Services Administration

•Implement MSHC Quality Plans at practice site(s) which is multidisciplinary and support the continuum of patient care needs

•Monitor quality of patient care prepare, regular reports of quality indicators, and initiate appropriate interventions as needed; in order to meet or exceed customer expectations and established standards/benchmarks

•Space Planning

•Participate in disaster planning to ensure continuity of service in extreme situations

•Staff Management

•Interview, hire, orient, lead, mentor, and evaluate performance of all staff under their direction to meet departmental and organizational needs

•Verify staff completes all Learning Management System (LMS) modules and has current licensure and certifications prior to deadlines/expiration (i.e. CPR)

•Perform other related duties and participates in special projects and assignments as assigned

Clinical

•Completes required orientation program and unit-specific competencies

•Assist physicians or residents with patient care when needed.

•Completes required orientation program and unit-specific competencies

•Assist physicians or residents with patient care when needed.

•Other duties as assigned.

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