CNM II Quality & Continuous Improvement (CI) Job Description - UPMC

CNM II Quality & Continuous Improvement (CI) Job Description

Job Description

Post Details

Post: CNM II Quality & Continuous Improvement (CI)

Reports To: Senior Director of Quality and Patient Safety

Accountable To: Senior Director of Quality and Patient Safety

Overview of the Post

The position of Quality & CI Manager (CNM II) will ensure that quality improvement activities are directed toward continuous quality improvement. The Quality & CI Manager identifies opportunities for improvement based on evidence-based practices, understanding of data, regulatory and accrediting agency requirements, and monitoring of high risk, high volume and/or problem prone processes by supporting the design, monitoring, analysis and improvement of patient care and organizational functions while implementing the day-to-day Quality Management Program functions.

Continuous Quality Improvement

· The Quality & CI Manager performs, coordinates, and facilitates quality improvement, patient safety activities, and clinical effectiveness initiatives to achieve organizational goals. This involves performing the assessment and analysis of operations and processes and working collaboratively with staff and managers to promote, design and implement quality improvements and innovations.

· Utilize and develop valid internal and external standards to measure quality.

· Works to promote quality improvement and innovation and monitors progress towards goals by collecting accurate, timely data to display the quality, cost, and service outcomes.

· Provides content knowledge in the interpretation, implementation, and maintenance of all accreditation, national quality assurance standards or regulatory standards to match external requirements.

· Maintains accountability for ongoing self-development activities, especially related to presentation facilitation, change management and application of quality improvement activities.

· In order to achieve defined outcomes the Quality & CI Manager engenders commitment, encourages cultural changes, disseminates information, and provides support for behavioural safety process changes.

· Liaison with UPMC International Quality teams, to standardise and maintain quality metrics.

Clinical Data

· Co-ordinate the capture of data and analyses clinical information from a variety of internal and external sources relating to patient safety, utilization of resources, system problems, and other quality functions.

· Identifies trends, variances, deficiencies, and problems utilizing aggregated data and information and works with multidisciplinary teams on improvement efforts.

· Supporting Departmental statistical data analysis. This includes providing meaningful statistics that describe the day to day operations of the unit, identify strengths and opportunities for clinical outcomes improvement

· Ensure quality assurance data is kept updated to meet all accreditation, regulatory and national quality assurance programme requirements while ensuring the integrity of data quality.

· Ensure clinical indicators are collated and reported as required for governance.

Quality Improvement Projects

· Liaises with the Project Management Office and Business & Process Improvement Manager Consults with Managers to deliver organisational projects.

· Liaises with department leads and critical committees as appropriate to finalise and advance the quality project goals.

· Leads or co-facilitates teams by coaching and advising team members to fulfil their role in a project team.

· When assigned, completes special projects and performs other related duties according to agreed upon goals and parameters.

· Utilize Lean Six Sigma tools in quality improvement projects.

Risk Management

· Provide the leadership for creating a culture of patient safety and works across departments to ensure compliance to accreditation standards, International Patient Safety Goals, and promotes Proactive Risk Management activities.

· Work with departments to develop departmental risk registers.

· Engage in Audit and coordinate data as per heading 2 above.

· Review all incidents to ensure corrective and preventative actions are implemented, incidents are graded, and learning is communicated.


· Review all complaints to ensure corrective and preventative actions are implemented, and learning is communicated.

· Where required meet with all complainants to hear their complaint and to communicate close out actions.


· Develop and deliver education and training regarding quality and risk issues.

Skills Essential to the Post

· Experience of working with multi-disciplinary teams
· Have good IT skills and ability to learn data bases
· Evident experience of managing change
· Excellent interpersonal and communication skills and the ability to motivate, influence, inspire and encourage different ways of working
· Good organization skills and analytical skills including problem-solving
· Self-starter with the ability to learn quickly
· Ability to prioritise and to deliver to short deadlines
· Excellent verbal, written and presentation skills
· Effective team player both as a facilitated and a worker
· Flexible and adaptable approach to work
· Knowledge of quality improvement concepts and methodology, knowledge of The Joint Commission standards and regulatory requirements.
· Good understanding of or willingness to learn Lean six sigma methodology.
· Self-initiative, ability to do detailed work, with accuracy and uphold confidentiality standards.


Person Specification Essential Desirable
Qualifications · Degree or Higher-level Healthcare qualification
· Post graduate education in Quality in Healthcare
Yes Yes
(Amount and Type)
· A minimum of 6 years of previous health care experience
· Previous experience of quality improvement projects in healthcare.
· IT Skills in Microsoft word, excel and PowerPoint.
Job Specific Competencies and Knowledge: · Ability to work on own initiative, independently, but also as part of multi-disciplinary team.
· Must have good working knowledge of data collection, and dissemination.
· Willingly puts forth effort in starting job duties on a regular basis; contributes new ideas; seeks self-improvement; masters new job duties
· Ability to deliver training and education



Personal Competencies: Acts in accordance with the vision, mission, and values of UPMC and in compliance with hospital policies. Yes

This job description is intended to be an outline of the areas of responsibility. As the UPMC Whitfield and the post holder develop, this job description may be subject to review in light of the changing needs of the Hospital.

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