Quality Systems Manager

Description

Position Summary

The Quality Systems Manager is responsible for managing and continuously improving the organization’s Quality Management System (QMS) to ensure consistent compliance with regulatory requirements, internal policies, and industry standards. This role serves as the operational lead for quality activities, including audits, process improvement initiatives, and data reporting.

The Quality Systems Manager collaborates closely with department leaders, union supervisors, and frontline staff to sustain a culture of quality, safety, and continuous improvement. The position provides technical leadership, oversight, and training to ensure that all services and operations meet organizational standards and regulatory expectations.

Key Responsibilities

Quality Management System (QMS)

• Maintain and enhance the organization’s QMS, including document control, CAPA (Corrective and Preventive Actions), internal      audits, and performance metrics.
• Monitor compliance with internal policies and applicable regulatory and accreditation standards.
• Ensure quality documentation is accurate, current, and accessible.
• Coordinate periodic management reviews of QMS performance.

Auditing & Monitoring

• Plan and conduct internal audits across departments to verify adherence to established procedures and compliance requirements.
• Prepare reports summarizing audit findings, corrective actions, and follow-up outcomes.
• Track and report quality trends, indicators, and performance metrics to the Director of Risk, Compliance & Quality Oversight.

Continuous Improvement

• Lead and support continuous improvement initiatives, including process standardization, workflow redesign, and staff engagement in problem-solving.
• Facilitate root cause analysis and develop sustainable solutions for recurring issues.
• Partner with operations and union leaders to integrate quality improvement efforts into daily practice.

Training & Support

• Provide quality system training, coaching, and technical support to managers, supervisors, and staff.
• Collaborate with Learning & Development or Education teams to incorporate quality principles into employee orientation and ongoing education.
• Promote a proactive culture of safety, compliance, and accountability throughout the organization.

Data, Reporting & Collaboration

• Collect, analyze, and present quality data to leadership and committees as directed.
• Support risk management and compliance activities through data sharing and coordination with the Director.
• Participate in multidisciplinary committees and projects to align quality and compliance initiatives.

Other Duties

Perform other duties as assigned, which may include but are not limited to:

• Supporting organizational survey readiness and accreditation activities, including preparation for regulatory or external      audits.
• Assisting in the review, revision, and implementation of organizational policies and procedures to ensure ongoing compliance and alignment with best practices.
• Participating in risk assessment and mitigation initiatives in coordination with the Risk and Compliance teams.
• Providing input and support for safety, performance improvement, and compliance committees as directed.
• Accessing Protected Health Information (PHI) as needed to promote high-quality care and protect the public’s health and      well-being.

Qualifications

Education

• Quality Management, Healthcare Administration, Industrial Engineering, or a related field required.

Experience

• Approximately five years of progressive experience in quality systems, process improvement, or compliance, or an equivalent blend of training and hands-on leadership experience in a regulated or process-driven setting.
• Experience in a unionized setting strongly preferred.
• Demonstrated success implementing or managing a Quality Management System.

Knowledge, Skills & Abilities

• In-depth understanding of quality assurance principles, process improvement methods (Lean, Six Sigma, etc.), and compliance      frameworks.
• Strong analytical, organizational, and communication skills.
• Ability to lead and influence cross-functional teams.
• Experienced in collecting, analyzing, and presenting quality data using a variety of reporting and analytic tools.
• Demonstrated ability to work collaboratively across all levels of the organization, including unionized teams.

GENERAL ACCOUNTABILITIES

1.Greets all patients, visitors, physicians, and other staff members in a courteous, respectful and professional manner at all time. Responds to all patients with empathy and positive interpersonal skills at all times.

2.Reports for scheduled shift on time and prepared to assume responsibilities.

• Reports to work in proper uniform/attire.
• Leaves for meal break on time and returns on time.
• Varies work schedule to meet the needs of the department.
• Ensures the department manager has approved all scheduled overtime.
• Seek supervisor approval before working beyond scheduled hours that will result in overtime.
• Schedules all time off with supervisor’s approval.
• Strictly adheres to hospital attendance/tardiness policies 100% of the time.
• Performs all duties as assigned.
• Wears I.D. badge in a visible location at all times on hospital property.
• Protects I.D. and access badge and reports any issues or loss immediately to supervisor or to the Human Resource Department.

3.Attends and participates in meetings and is responsible for information communicated at meetings and in email.

• Attends all mandatory in service on a timely basis as scheduled.
• Participates as an active team member at staff meetings.
• Reads communications and acts upon in a positive and informative manner.

4.Identifies own educational needs and maintains appropriate skill level through educational opportunities.

5.Exercise a commitment to practicing behaviors that are in agreement with the spirit of cooperation and reflect the values described in the Code of Mutual Respect and Professionalism.

6.Assists all patients, family members, physicians, visitors, and employees in a professional and courteous manner.

• Extends special attention and sensitivity to all patients, visitors, physicians, and fellow employees.
• Actively promote diversity and inclusion across organization for both patients and coworkers while avoiding any language or actions considered to be discriminatory or derogatory regarding race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability, veteran status, military obligations, and marital status.
• Assists in maintaining an atmosphere of cooperation and teamwork with other departments and community partners.
• Demonstrates a genuine willingness to prevent or resolve inter-personal conflicts.
• Demonstrates the ability to participate in and/or implement team decisions.
• Adheres to HIPAA and all applicable privacy laws at all times, only sharing information on a “need to know” basis.

7.Follows Infection Control procedures at all times.

• Clinical Personnel: Strictly adheres to standard precautions by adhering to the usage of personal protective equipment when handling blood or body fluids.
• Non-Clinical Personnel: Washes hands and other skin surfaces with soap and water thoroughly and often in an effort to control spreading of germs within the department and facility.
• Adheres to isolation procedures at all times as applicable.

8.Adheres to the following environmental care standards.

• Demonstrates adequate knowledge of safety policies and procedures, the use of MSDS sheets, hazardous material procedures, and safety codes.
• Code Blue, Code Gray, Code Silver, Code Amber, Code Red, Code Orange, Rapid Response Team
• Demonstrates adequate knowledge of security issues, i.e. personal protection, protection of personal and hospital property.

9.Be familiar with and comply with the Mid-Valley Hospital & Clinic Personnel Handbook and Policies.

10.Be familiar with the collective bargaining agreement (Union Contract) of the UFCW 21 and Mid-Valley Hospital.

11.Demonstrates the ability to adapt to varied age-specific patient populations.

• Non-Clinical Personnel: This position has no responsibility for the assessment, treatment, or care of patients. However, the ability to communicate and interact with patients of all ages is required.

Requirements

  Qualifications

Education

• Quality Management, Healthcare Administration,  Industrial Engineering, or a related field required.

Experience

• Approximately five years of progressive experience in quality systems, process improvement, or compliance, or an equivalent blend of training and  hands-on leadership experience in a regulated or process-driven setting.
• Experience in a unionized setting strongly preferred.
• Demonstrated success implementing or managing a Quality Management System.

Knowledge, Skills & Abilities

• In-depth understanding of quality assurance principles, process improvement methods (Lean, Six Sigma, etc.), and compliance      frameworks.
• Strong analytical, organizational, and communication skills.
• Ability to lead and influence cross-functional teams.
• Experienced in collecting, analyzing, and presenting quality data using a variety of reporting and analytic tools.
• Demonstrated ability to work collaboratively across all levels of the organization, including unionized teams.

Working Conditions

• Primarily office-based with routine visits to operational and clinical areas.
• Occasional travel between sites may be required.
• Must be able to attend meetings outside normal business hours as needed.

Position Impact

This position plays a critical role in ensuring that the organization’s quality systems are effectively implemented, compliant, and continuously improved. Through collaboration, coaching, and data-driven decision-making, the Quality Systems Manager supports a culture of excellence, accountability, and safety under the direction of the Director of Risk, Compliance & Quality Oversight and the Chief Medical Officer.

This job description is intended to describe the general nature and level of work performed. It is not an exhaustive list of all duties, responsibilities, and qualifications required of the position.

WAGE AND COMPENSATION

Wage range $36.00  hr. - $ 53.00 hr.   – DOE  $75,000 - $110,240 annually

Mid-Valley Hospital offers a benefit package. This includes accrued vacation time in the amount of .09615 vacation hours per hour worked.  Accrued sick leave at an accrual of .04615 per hour, Life insurance and a profit-sharing plan. We also offer medical, dental and vision insurance plans. Employees can enroll in a 403(b) deferred compensation plan and/or a 457 deferred compensation plan.