Manager - Quality Improvement

York, PA | Professional | Tracking Code: 65485

Job Description:

Under the general supervision of the Regional Director-Quality Improvement and with a matrixed relationship to the local VP-Medical Affairs (VPMA)/Chief Medical Officer (CMO), leads and facilitates concurrent reviews and quality/performance improvement team activities relating to public reporting of quality data and accreditation. Facilitates and/or supports the Quality and/or Performance Improvement Committee in support of the VPMA/CMO and ensures appropriate and timely reporting schedule in accordance with accreditation, governance and regulatory requirements. Acts as the quality data subject matter expert for the local entity. Supervises workflow, inclusive of timeframes and deliverables, for concurrent review or audit team(s) and/or subcommittees/workgroups, with dependable and excellent quality assurance. Reviews quality dashboards daily for outliers and trends and uses critical thinking to determine areas of focus and next steps. Champion of the Accountability Model/QIRS scoring method for quality risk assessment. Coordinates with clinical experts and system resources as appropriate.


Duties and Responsibilities

Manages, and is the subject matter expert for, inpatient hospital quality measures and measure definitions/requirements, including the provision of clinical recommendations/interventions for performance improvement based on past, present and projected results.

  1. Leads the training and education in quality assurance for the local entity.
  2. Reports or delegates quality results to the Quality Committee oversight committee.
  3. Works collaboratively with Accreditation, Patient Safety, Infection Control, Performance Improvement, Regulatory Compliance, Clinical Improvement, Nursing, Physician staff, HIM, Imaging and all other interdisciplinary customers, in order to best address quality improvement opportunities.
  4. Establishes tools and specific criteria for review of patient medical records concurrently, but at times retrospectively throughout inpatient hospitalization or outpatient service as directed by the Regional Director of Quality Improvement. Focus of reviews will primarily involve publicly reported quality measures and Joint Commission certifications activities. Reviews items such as clinical documentation review reports, clinical records, external benchmarking reports, public reporting measures reports and identifies gaps relating to data accuracy, documentation and/or process variation.
  5. Facilitates and drives hospital improvement teams to rapidly improve overall hospital-wide compliance of clinical and patient safety measures that are publicly reported.
  6. Provides communication and action tools to encourage concurrent quality team development of methods to track and ensure sustained improvement over time.
  7. Runs and validates data reports from internal databases, as needed. Performs other clinical data analyst duties as needed.
  8. Participates in Hospital/Clinical Effectiveness Team (CET) meetings as requested.
  9. Develops and coordinates education materials and programs to maintain awareness of quality improvement or accreditation topics.
  10. Establishes connections within the WSH system quality structure, Quality Council and the WSH regions and entities.
  11. Ensures alignment with a standardized communication process for strategy and engagement.
  12. Develops professional education for a broader skill pool for staffing coverage, training, professional development, collaborative work efforts, team development and employee satisfaction.
  13. Engages in and supports the regional model that bridges multiple entities within a geographical region for easier identification of process/policy gaps and differences and related reporting and discussion, with the goal of continuous improvement and early identification of risk.
  14. Working with the local VPMA/CMO/CNO, identifies, determines, and implements best practice(s) for clinical/ operational support.
  15. Shares and spreads best practice processes, utilizing Lean methodology inclusive of A3 problem solving, LDM improvement methodology, and standard work.
  16. Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or hospital.


  • Notes:
    • Other combinations of formal education, training and experience may be considered.
  • Minimum Experience:
    • More than 3 years’ clinical experience and health care system administration. At least one year experience with hospital accreditation and national quality measures. Three years’ experience with supervision/team leadership over clinical staff, and related policy and procedure development.
  • Minimum Education:
    • Bachelor’s Degree
  • Minimum Field Of Expertise:
    • Healthcare quality assurance; experience in a managed care setting desirable
    • Preferred Cert/RegistrationRegistered Health Information Administrator (RHIA); Certified Health Data Analyst (CHDA); Certified Professional Healthcare Quality (CPHQ); licensure as a medical professional or registration and current RN license in PA
James Kane
James Kane
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)