Quality Manager

• Develop, implement, and manage a comprehensive quality management program tailored to the unique needs of OakLeaf Surgical.
• Collaborate with departmental leaders to establish and maintain quality indicators, benchmarks, and performance metrics.
• Facilitate performance improvement initiatives to enhance patient outcomes, patient safety, and overall efficiency.
• Implement benchmarking activities to compare the hospital’s performance with industry standards.

• Monitor and evaluate clinical and non-clinical processes to identify opportunities for improvement.
• Lead efforts to prepare for and participate in accreditation surveys, certification surveys, and regulatory audits.
• Conduct root cause analyses, high priority reviews, and proactive risk assessments.
• Build relationships with providers to ensure patient safety and regulatory compliance are followed.
• Implement corrective action plans to address identified issues.
• Utilize data analytics to assess and report on key performance indicators, trends, and areas for improvement.
• Develop and present regular reports to hospital leadership, medical staff, and relevant committees.
• Lead the education department to design and deliver training programs related to quality improvement, patient safety, and regulatory compliance.
• Lead risk management to identify, assess, and mitigate potential risks to patient safety and quality of care.
• Participate in the development and implementation of risk reduction strategies.
• Foster collaboration and communication among various departments, medical staff, and other stakeholders to achieve quality improvement goals.
• Chair and participate in Performance Improvement and Safety Committee.
• Chair and participate in Administrative Policy Committee.
• Chair and participate in Health Equity Committee.
• Participate in the following committees: Emergency Management, Total Joint Certification, Educational Council, Antibiotic Stewardship, Utilization Management, and Water Management committees.
• Oversee Infection Control and Employee Health program to ensure compliance with regulatory bodies.
• Serves as a member of the Internal Review Board and the Medical Executive Committee
• Develops and implements solutions to meet the ongoing documentation requirements of the hospital while maintaining patient safety.
• Stay informed about industry best practices and trends in quality management for surgical hospitals.
• Completes annual review of assigned policies.

• Direct, administer and manage the operations of assigned functions.
• Assign tasks and review work of direct reports.
• Monitor direct reports adherence to Hospital protocols and procedures.
• Provide performance management directive including annual evaluations, coaching, development and corrective action.
• Engage in staff development through education and training.
• Ensure direct reports have adequate equipment and resources to carry out high quality patient care.
• Ability to perform as administrator on-call rotation.
• Ability to attend meetings outside of normal business hours as needed.

• Ability to take control of situations and dictate subordinate activities in a responsible manner.
• Ability to instruct and train in policies and procedures.
• Ability to prepare performance evaluations and make recommendations regarding unsatisfactory employees.
• Ability to assign work, add or delete, plan work and establish priorities.
• Ability to comprehend, retain and apply the requirements of any governmental or regulatory body.
• Ability to exhibit strong communication, presentation and listening skills to ensure facility-wide collaboration and coordination.
• Ability to build consensus and commitment among various stakeholders.
• Ability to understand and address complex issues in the critical areas of healthcare, including but not limited to regulatory/legislative changes and physician partnerships.
• Ability to maintain high ethical standards, integrity, and professionalism consistent with OakLeaf’s Customer Service Standards
• Ability to relate and work effectively with others.

• Ability to operate various types of equipment – standard office equipment, computers, and intermediate knowledge of Microsoft Office and other programs as assigned.
• Ability to use Electronic Medical Record system.
• Other equipment could be required.

• Ability to define problems and deal with a variety of situations.
• Ability to make decisions independently with strong decision-making capability.
• Ability to think quickly, maintain self-control, and adapt to stressful situations.
• Ability to use a fact-based approach to assessing and designing solutions.

• Ability to exhibit excellent communication, presentation, and listening skills.
• Ability to communicate effectively with other members of the staff, physicians, patients, and corporate partner.
• Ability to develop, interpret and implement local policies and procedures; general correspondence; and Federal, State, and local regulations.
• Ability to communicate in English in both written and verbal format.

• Demonstrates eligibility for employment in the U.S.
• Bachelor’s degree in Nursing required.
• Master’s degree in business, healthcare administration is preferred.
• Five (5) or more years of healthcare experience required.
• Registered Nurse licensure in the state of Wisconsin required.
• Leadership experience preferred.
• Intermediate experience in Microsoft Office required.
• Certified Professional in Healthcare Quality (CPHQ) required within 24 months of hire date.

• Comprehensive health, dental, and vision insurance
• Health Savings Account with an employer contribution
• Company paid life insurance
• Free meals
• PTO
• 401(k) retirement plan with 4% company match
• Tuition reimbursement
• Wellness reimbursement

OakLeaf Surgical Hospital