Job Details Level Management Position Type Full Time Job Category Management Description About Lakewood Lakewood Health System is a comprehensive rural healthcare system in central Minnesota. Leading the way in providing quality, personalized healthcare for a lifetime, Lakewood prides itself on remaining fiercely independent to prioritize its patients, staff, and communities in all decisions. Voted as one of Star Tribune's Top Workplaces for the third year in a row, we do rural healthcare differently at LHS by providing a solid foundation of family practice providers with access to best-in-class specialty services, all right here at Lakewood. Across the spectrum of life, Lakewood Health System provides compassionate, quality care for the Brainerd Lakes region and beyond. About the Unit/Department/Team The Manager of Hospital Quality, Risk Management & Regulatory Services will work with a multi-disciplinary team across the system, reporting directly to the Executive Director of Nursing. This person should thrive working independently, but remain talented in connecting with other nursing leaders to strategize, implement and evaluate patient safety and quality initiatives. Mission for Position The Manager of Hospital Quality, Risk Management & Regulatory Services leads patient safety and quality programs to ensure every patient receives high quality care, while ensuring Lakewood fulfills its regulatory compliance responsibilities. Position Summary Hospital Quality Assurance and Patient Safety Develop, plan and implement system-wide patient safety and quality assurance initiatives Identify trends and conduct root cause analysis for identification of process changes needed Ensure QA initiatives are followed through by departments Train, collaborate & communicate to achieve patient safety and quality assurance goals. Works to ensure staff, specifically nursing directors and leads have a working knowledge and process for operational and effectiveness with patient safety. Works collaboratively with an interdisciplinary team to ensure the environment is centered on patients, families, safety and quality. Works collaboratively with quality leaders across the system including the Senior Services Quality manager, the Performance Excellence & Talent division, and the Medical Director to develop methods and/or systems for improving quality care, service and measurement outcomes. Communicates and collaborates with the leadership, physicians, extenders and staff as to the quality improvement plan and their respective responsibilities in carrying out quality improvement initiatives. Implementation, evaluation and reporting of Patient Safety and Quality Assurance Initiatives Maintains facility records, reports on adverse health events, completes root cause analysis, and conducts patient safety survey system-wide; action plans based on results. Works collaboratively with Minnesota Department of Health, Minnesota Hospital Association and other state and national quality improvement organizations to implement appropriate and required quality improvement reporting and activities. Coordinates abstraction and submission of data per Center for Medicare and Medicaid Services (CMS) specifications Serves as system administrator for QualityNet Regulatory Compliance Ensures compliance with external agencies that regulate critical access hospitals including but not limited to CMS and the Minnesota Department of Health Works directly with department managers and management teams to ensure compliance to regulations and that Lakewood is survey-ready at all times. Coordinates all survey activities including the MDH surveys for compliance with the Conditions of Participation Position Type Full-time, exempt Qualifications Qualifications Current MN RN licensure in good standing with the MN Board of Nursing required. BA/BS preferred. Three to five years of current clinical nursing experience in an acute care setting required. Preferred experience or training in qu lity, patient safety and regulatory work. Expertise in data collection and analysis, report writing and data presentation. Able to work independently and take initiative in completion of tasks. Proficiency with Microsoft Office suite applications (Word, Excel, PowerPoint, etc.) and other software programs Facilitative resolution skills. Program and project management skills. Ideal Candidate Ability to problem-solve. Ability to multi-task. Ability to organize, coordinate and prioritize tasks. Ability to communicate effectively with customers and co-workers both verbally and in writing. Benefits Lakewood Health System is growing and looking for great people to join our mission of providing personalized, quality healthcare for a lifetime. At Lakewood, our people are our most valued asset! Generous Flex Time Off & Wellness Time Off 401K Match Annual tuition assistance of $2,000 per year Best-in-region employer HSA contributions New in 2024 - employer paid premiums for individual-only healthcare coverage! With ample opportunities for growth within the system and support as you pursue your personal goals, it's safe to say that Lakewood Health System is a great place to launch or continue your career in healthcare! Next Steps Interested, but will the schedule work for you? Have questions on organizational culture, team fit or day-to-day experience? >>>Contact Corrine Neisess to discuss the possibilities further: Corrine Neisess, VP of Nursing P: 218-894-8429 E: corrineneisess@lakewoodhealthsystem.com Apply Online | Lakewood Health System provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability and protected veteran status. Lakewood Health System is deeply dedicated to diversity in the workplace. We are an Equal Opportunity / Affirmative Action Employer (Minorities / Females / Disabled / Veterans)