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"Real Leaders are Ordinary People with Extraordinary Determination" (unknown)








  • Bachelor’s degree in nursing required

  • Licensed Registered Nurse in the State of Washington (or willing to obtain upon hire)

  • Three years of experience in a managerial or supervisory capacity

  • Five years related professional/technical experience

  • Experience with Joint Commission, CMS and Department of Health regulations

  • Previous experience with computerized information systems (email, MS Office, hospital systems, etc)


Job Description

The Manager of Quality is responsible for the leadership, design, plan, implementation and evaluation of the quality management program, accreditation and regulatory compliance for the assigned hospital/locations.  The manager analyzes healthcare processes and patient outcomes, develops outcome measures, monitors sensitive quality outcome indicators, evaluates the impact of improvement activities to identify areas for improvement, and ensures the appropriate use of services, resources, and evidence based care provided to patients. The manager supports the organizations’ quality objectives by assuring work meets standards, internal/external deadlines are met within established time frames, and progress is satisfactory achieved in all aspects of the area of focus. 




Regulatory Compliance & Accreditation (CMS, TJC, WA DOH)

  • Provides consultation and support to teams or departments related to regulatory compliance improvement initiatives and events.

  • Participates in regulatory and accrediting surveys and audits

  • Assists departments in identifying and correcting regulatory compliance issues and participates in preparatory activities for regulatory agencies.

  • Monitors performance for compliance with all applicable agencies as may be required

  • Develops documentation and other processes designed to assure attainment of Joint Commission standards as well as compliance with the CMS Conditions of Participation and Washington Department of Health standards.


Clinical Outcomes

  • Leads, designs, plans, implements and evaluates hospital-wide quality management program focused on clinical outcomes, including core measures, readmissions, and mortality data in support of the institute’s achievement of Quality objectives. 

  • Analyzes healthcare processes and patient outcomes, develops outcome measures, monitors sensitive quality outcome indicators, evaluates the impact of improvement activities to identify areas for improvement, and ensures the appropriate use of services, resources, and evidence based care provided to patients. 


Project Management & Data Analysis

  • Coordinates analysis and system reporting for projects and activities, and develops recommendations, based on research and findings, for appropriate actions by departments/organizational committees.

  • Develops outcomes-oriented work plans for assigned projects, to include plans that address potential barriers to successful implementation, and design interventions aimed at minimizing transition problems.

  • Evaluates the effectiveness of processes for patient outcomes, staff development and maximization of financial resources.


Customer Concern/Complaint Activities

  • Manages the overall customer concern and grievance process, establishing and implementing policies, standards, and systems to integrate effectively and horizontally with the department’s objectives.


  • Identifies and provides expertise to clinical leaders to support the success of service recovery initiatives


  • Supervises employees by providing direction and guidance, and administering management functions within the provisions of organizational policies and standards and federal, state and local regulation.


  • Adheres to Attendance and Punctuality Policy and Procedure standards, and maintains reliable attendance.


  • Contributes to the success of the organization by meeting organizational competency   expectations and core values (respect, integrity, stewardship, excellence, collaboration and kindness), continuously learning, and by performing other duties as needed or assigned.




Personal Competencies          

  • Integrity

  • Accountability

  • Self-Development

Interpersonal Competencies

  • Communication

  • Collaboration

  • Fostering Teamwork

  • Developing Others

Organizational competencies

  • Customer Focus

  • Quality and Strategic Focus

  • Financial and Operational Management






  • Knowledge of and experience with managing quality data

  • Knowledge of acute care health system delivery and clinical practice

  • Knowledge of clinical documentation requirements

  • Knowledge of change principles and leadership skills for effective change management

  • Knowledge of the principles of information management in order to effectively analyze data and make decisions

  • Knowledge of project management techniques

  • Skill in providing leadership and in the mentoring of staff

  • Skill in analyzing, designing and implementing change processes

  • Skill at developing and implementing process improvement projects

  • Ability to work across non-traditional boundaries and the ability to work several projects at once

  • Ability to establish and maintain a high-performing work team

  • Ability to establish a climate to achieve optimal performance levels

  • Ability to communicate effectively

  • Ability to work in a cross functional team environment, both within the department, hospital and within the system

  • Ability to delegate effectively

  • Ability to work independently and take initiative

  • Ability to deal effectively in constant change

  • Ability to determine need, develop programs for learning and implement team approach for change

  • Skill in time management and ability to meet deadlines

  • Ability to accept responsibility willingly

  • Ability to communicate effectively

  • Ability to set priorities and use good judgment

  • Ability to be caring, sympathetic, calm, and able to work as part of a team



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