GENERAL SUMMARY: (Must include Reports to)

Supports Beaumont Health by managing and coordinating quality, safety and performance improvement (PI) projects, and Peer Review activities when necessary. In addition, the manager provides data analysis, quality and PI education and training for staff and leaders, process flow and operational analysis. He/she partners with administrators and other leaders in strategic planning, business development, project management, and operational efficiency efforts across the hospital. In addition to site-specific responsibilities, he/she works cooperatively and collaboratively with Beaumont Health leaders at other sites related to see new system-wide initiatives through to success.

The manager reports to the Director of Nursing or Quality Department. The manager may have direct reporting FTE’s, which would be dotted line to the Director of the department.

AREAS OF RESPONSIBILITY:

• Quality

• Performance Improvement

• Project Management

• May include additional responsibilities ie: Peer Review; Nursing Quality Metrics; and leading PI teams as assigned by Director.

ESSENTIAL DUTIES:

1. In partnership with the Director, establishes site-specific strategic priorities related to quality and performance improvement, to ensure alignment with the hospitals’ strategic plan and the health system’s Key Goals.

2. Manages, facilitates and coordinates all PI initiatives at the BH hospital as assigned. Methodologies are applied using the analytical tools and concepts of Kaizen, PDCA, Six Sigma and Lean.

3. Continuously develop and improve the processes and templates, and facilitate projects involving Performance Improvement (PI), Six Sigma and Lean.

4. May facilitate, coordinate and manage Kaizen activities, including development of A3 documents.

5. May lead Physician Practice Evaluation when assigned

6. May lead Nursing Quality Metrics when assigned

7. Provides education, coaching and mentoring for other leaders and staff

This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.

STANDARD REQUIREMENTS:

1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.

2. Supports the Patient and Family-Centered Care (PFCC) model:

• Treats individuals with dignity and respect

• Shares complete and unbiased information with patients and their families

• Encourages and supports patient and family participation in their care

• Partners and collaborates with patients, families, and team members to ensure an excellent and positive patient experience.

3. Supports and contributes towards the BH culture:

• Brings best self to work each day

• Is highly engaged

• Reflects a team-oriented approach

• Strives for excellence

• Treats patients, families, and co-workers with compassionate, extraordinary care every day

4. Supports and contributes towards the BH Just Culture Environment:

• Encourage employees to report safety and quality concerns and encourage their participation in redesigning systems and processes to minimize the risks of errors from happening.

• Just Culture is about creating an environment where employees are encouraged to do the right thing, including reporting safety and quality concerns, so that we do not compromise our values in pursuit of our mission.

5. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.

6. Supports and adheres to all Beaumont Health’s customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.

7. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.

8. Supports and participates in a collaborative team -oriented environment – cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.

9. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules – including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.

10. Completes all required compliance standards that may be department specific and/or identified by the organization.

11. Maintains current licensure, registration and/or certification, as applicable, at all times.

KEY LEADERSHIP COMPETENCIES:

1. Builds Trust

2. Creates and Communicates Clarity

3. Works Collaboratively and Fosters Teamwork

4. Builds a Cohesive Team

5. Utilizes Strategic Judgment

6. Cultivates a Service-Oriented Culture

7. Creates and Communicates Vision and Strategy

8. Leads Change and Innovation

STANDARD QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

A. Education / Training:

• Bachelor’s degree in Nursing, Industrial Engineering, Health Care Administration, or related field is required.

• Master’s degree in Healthcare Administration or Business Administration is preferred.

B. Work Experience:

• 3 years of healthcare experience required; 5 years of healthcare experience preferred.

C. Certification, Licensure, Registration:

• PDCA, Kaizen, Lean, Six Sigma and other performance improvement or project management certifications preferred.

D. Other Qualifications:

• Demonstrates leadership strengths in the areas of objectivity, collaboration, teamwork, and initiative.

• Demonstrates computer skills with proficiency in Microsoft Outlook, Word, Excel, PowerPoint required; statistical, database, flowchart and project management software program knowledge preferred.

• Demonstrates ability to learn and apply advanced statistical tools to yield objective, quantitatively driven recommendations.

• Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.