Radiology Quality and Safety Manager 70002

Full Time Day 8a4p/9a5p

Position Summary:

The Radiology Quality and Safety Manager serves as a role model and works collaboratively with departmental leaders and staff to ensure a smooth functioning highquality (efficient and effective) patient care operations with evidencebased practices that support all quality pillars within the Department of Radiology. The Quality and Safety Manager leads multidisciplinary teams and assists in the development of department goals and objectives and works with the departments leaders and staff to achieve key organizational goals in quality ensuring alignment with hospital initiatives projects and functions while serving as a positive change agent.

Essential Functions and Responsibilities Includes the Following:

1. Understands and adheres to our

Performance Standards Policies and Behaviors.

2. This position is responsible for establishment implementation and monitoring of the centralized Performance Improvement/Performance Control Plan for the Department of Radiology under the direction of the Department Administrator.

3. The Quality and Safety Manager will lead multidisciplinary teams to coordinate improvement efforts manage departmental policies and educate on the latest guidelines and regulations from TJC ACR DOH MQSA and other regulatory bodies.

4. The ability to work collaboratively across departments is key. This includes but is not limited to; the emergency department inpatient hospital operating room risk management outpatient imaging sites and all other areas where radiology impacts patient care.

5. The incumbent will function as the administrative and technical leader for ensuring all goals for quality and safety compliance and accreditations are met in accordance with regulatory guidelines and policies.

6. Responsibility includes oversight tracking and coordination of patient identification Hand Hygiene and Infection Control Compliance.

7. Collaboration of ACR Accreditation programs including tracking and reporting of Dose Optimization Dose Monitoring Alerts/ Committee updates.

8. Oversight and preparation for DOH Inspection TJC and ACR/DICOE Readiness & Compliance rounding preparations and audits.

9. Develops longterm strategic plans for improvement with a focus on quality patient engagement and operational efficiency under the guidance of the Department Administrators.

10. Works with physician leadership to develop analytics and scorecards to support an ongoing physician quality council.

11. Tracks and Analyzes data (e.g. patient satisfaction efficiency LOS) and provides clear and meaningful recommendations for improvement.

12. Conducts root cause analysis and uses other quality tools at expert level to drive quality improvement based on quality events and/or data (i.e. experience using a quality management system for tracking trending and maintaining improvement initiatives).

13. Promotes a serviceoriented culture of safety through training coaching and engagement with frontline staff.

14. Continuously evaluates existing work processes and staff functions for opportunities to improve quality safety and performance. This includes the development of A3 s and action plans with a focus on longterm sustainment.

15. Monitors benchmarks to assess performance level and recommends actions for achieving best practice levels of performance.

16. Monitoring and compliance of PDM Monitor testing.

17. Tracks and oversees systems used for critical and incidental findings.

18. Addresses all patient complaints and collaborates with departmental leaders to identify root cause.

19. Tracking and report out of dashboard metrics of OK QA and Radiologist Peer Review.

20. Maintain relationships with internal and external Regulatory and Quality Liaisons.

21. Documents and Communicates Medical Device Recall with action plans and records outcomes.

22. Tracks mismatched studies and monitors outcomes using mPower dashboards in structured reporting system.

23. Performs all other related duties as assigned.

Education & Experience Requirements

Bachelor s degree required; master s degree preferred

Radiologic Technologist or RN license required.

7 years or more of experience in Radiology 3 of which must be in a leadership capacity.

Lean six sigma and other performance improvement experiences preferred.

Proven track record in creating and sustaining a culture of safety in Radiology.

Experience developing presentations analysis and other communication to provide recommendations to operational leadership on opportunities to improve.