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The Manager of Quality Improvement assists the DCQI in the operations of the hospital's Quality / Performance improvement program.  Supports quality and process improvement efforts identified in the hospital. Responsible for data tracking/collection and trending.  Coordinates, assists and advises on a variety of meetings, seminars, services and/or programs related to the overall Quality / Performance Improvement program. Coordinates hospital wide performance improvement activities under the direction of the DCQI.  

Carondelet Holy Cross Hospital Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

At Carondelet Holy Cross Hospital, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status

Holy Cross Hospital is a cornerstone of Nogales, providing emergency care, general surgery, labor and delivery services and important health and wellness education for residents across Santa Cruz County. This 25-bed, critical-access hospital has been a part of Carondelet Health Network since the Sisters of St. Joseph of Carondelet began managing the hospital in the early 1980s. The hospital is committed to high quality care and customer service for all who enter their doors. Join our team!

Special Skills

• Knowledge of CMS Conditions of Participation and accreditation standards.
• Understanding of quality improvement methodologies (PDSA, Lean, Six Sigma).
• Strong analytical and data interpretation skills.
• Experience with quality reporting systems and dashboards.
• Excellent communication and presentation skills.
• Ability to lead multidisciplinary teams and influence change.
• Strong project management and organizational skills.

Minimum Requirements

• Education: Bachelor's degree or higher in a patient care-related field.
• Experience: 3 years combined experience in hospital clinical practice and Quality Management. Minimum of 1 year in hospital Quality Management. Experience with regulatory and accreditation standards. Extensive experience in concepts associated with RCA's and developing, implementing, and monitoring robust quality and process improvement activities.
• Certifications/Licensure: CPHQ, CPPS, or CPHRM certification within 12 months of hire

• Experience: 1 year as a hospital Quality Manager
• Certifications/Licensure: Registered Nurse, CPHQ, CPPS, HACP-CMS

• Facilitate quality improvement projects using evidence-based methodologies and performance improvement tools.
• Monitor organizational quality metrics and identify opportunities for improvement.
• Facilitate development, implementation, and evaluation of corrective action plans.
• Support Quality Assessment and Performance Improvement (QAPI) activities.
• Assist departments in achieving quality and patient safety goals.
• Analyze clinical performance data and identify trends, risks, and improvement opportunities.
• Develop and maintain quality dashboards and scorecards.
• Collaborate with operational leaders to improve outcomes related to mortality, readmissions, hospital-acquired conditions, and patient experience.
• Ensure timely and accurate reporting of quality measures.
• Promote a culture of safety and high reliability.
• Support ongoing readiness for CMS, state, and accreditation surveys.
• Monitor compliance with regulatory and accreditation standards.
• Facilitate survey preparation, mock surveys, and corrective action plan development.
• Provide education regarding regulatory and accreditation requirements.
• Present quality and patient safety data to committees and leadership teams.
• Facilitate interdisciplinary teams focused on quality improvement initiatives.
• Support medical staff quality and peer review activities.