Quality Manager - OAK LEAF SURGICAL HOSPITAL LLC : Job Details

APPLICATION DEADLINE: 08/16/2025

Job Summary: The Quality Manager is responsible for leading and overseeing all aspects of quality management and performance improvement initiatives at OakLeaf Surgical. This position plays a crucial role in ensuring the delivery of high-quality patient care, compliance with regulatory standards, and continuous improvement of processes and outcomes.

Essential Job Functions

StrategicFunctions: • 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.

Operational Functions: • 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.

Leadership Functions: • 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.

Other duties as assigned.

Knowledge Skills and Abilities:• 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.

Equipment Knowledge Required: • 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.

Reasoning Ability: • 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.

Language Skills: • 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.

Mathematical Skills:Ability to perform intermediate mathematical calculations.

Qualifications:• 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.

Benefits:

• 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

Equal Opportunity EmployerThis employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.