MGR-QUALITY RN

General Purpose of Job:

The Hospital Quality Manager is responsible for overseeing, developing, implementing, and evaluating Sparrow health’s quality improvement programs. Manages administrative and operational objectives for the quality management department. This role ensures compliance with accreditation standards (e.g., Joint Commission, CMS), regulatory requirements, and internal performance benchmarks. The manager collaborates with clinical and administrative leaders to promote a culture of continuous improvement and safe, high-quality care delivery. Facilitates and supports process improvement initiatives using Lean principles to optimize hospital operations, reduce waste, and enhance patient care.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Manage operating functions of the department with direct supervision over performance improvement specialists and community hospital leads. Identify opportunities for improvement in departmental operations. Resolve issues swiftly and with minimal conflict. Makes decisions and provides directions to team members that support the goals and objectives established by the organization. Responsible for all subordinate staff activities related to human resource management (hiring, promotion, salary changes, performance coaching, disciplinary actions, training and development, ensuring consistent application of organizational policies, etc.
• Lead change and continuous improvement initiatives, with a specific focus on Healthcare Associated Conditions (HACs) across the organization as well as priorities identified in the quality management plan.

• Develop, implement, and manage hospital-wide quality improvement and performance initiatives.
• Monitor clinical and operational data to identify trends, issues, and opportunities for improvement.
• Ensure compliance with regulatory and accreditation requirements (e.g., Joint Commission, CMS, state health departments).
• Coordinate quality reporting and submissions to external agencies (e.g., NHSN, Leapfrog, HCAHPS).
• Provide leadership to quality committees and support departments in developing quality action plans.
• Educate staff and leadership on quality improvement methodologies, tools, and patient safety principles.
• Collaborate with IT, clinical informatics, and medical staff to optimize data collection and reporting processes.
• Prepare reports and dashboards to communicate performance metrics and outcomes to leadership.

License / Certification: • State of Michigan RN license • Lean Six Sigma certification (Green Belt, Black Belt, or equivalent preferred). • CPHQ (Certified Professional in Healthcare Quality) required upon hire or within 3 years of employment.

• A minimum of 3 years of progressively responsible work experience relative to quality management. • A minimum of 2 years of experience in Lean/process improvement required, preferably in a healthcare setting.

• Bachelor’s degree in nursing • Master’s degree in nursing or related field preferred.

• Strong business acumen and capability to effectively communicate with all levels of leadership. • Ability to drive change throughout the organization. • Ability to motivate and develop people to achieve results. • Skilled communicator with strong ability to influence others, coach, mentor, and motivator. • Ability to draw insightful impressions from objective data to identify process and organizational culture issues in need of improvement. • Skilled at facilitating multi-disciplinary meetings with physicians, clinicians, leaders, and frontline caregivers. • Ability to implement multiple simultaneous projects. • Ability to balance/prioritize tasks and projects. • High degree of innovation and creative problem solving. • Knowledge of Joint Commission, CMS Conditions of Participation, standards and survey process. • Skilled in analytics and driving results through data. • Strong facilitation, analytical, and communication skills. • Proven ability to lead projects and influence teams without direct authority. • Familiarity with healthcare operations, regulations, and quality improvement standards.