Healthcare Quality, Safety, and Experience Manager

The Quality, Safety and Experience Healthcare Manager leads and oversees the quality assurance, patient and team safety, accreditation, and patient experience programs for OrthoAtlanta clinical practices including Physical Therapy and MRI, and multiple Ambulatory Surgery Centers (ASCs). This position ensures that all locations meet regulatory requirements, maintain accreditation standards, implement effective quality assurance programs, and promote a culture of safety to deliver exceptional patient care. The position also plays an important role in enhancing patient satisfaction and overall experience by analyzing patient feedback, identifying trends, and developing innovative strategies to improve service delivery and patient care.

Key Responsibilities

Quality Assurance, Safety, and Performance Improvement

• Develop, implement, and monitor quality assurance, safety, and performance improvement programs tailored to orthopedic practices and ASCs and aligned with organizational goals and industry best practices.
• Work closely with operations and clinical teams to ensure consistent delivery of high-quality patient care.
• Oversee incident reporting, root cause analysis, and corrective action plans to ensure patient safety and process improvement.
• Lead quality improvement projects to enhance care, streamline processes, and reduce risks.
• Foster a culture of accountability and continuous improvement across the organization.
• Conduct regular audits and site visits to assess compliance, safety, and quality assurance performance.
• Train staff in regulatory and quality assurance processes, emphasizing compliance and safety.
• Create and update policies and procedures to align with best practices and regulatory standards.

Accreditation and Regulatory Compliance

• Maintain up-to-date knowledge of relevant federal, state, and local accreditation standards (e.g., AAAHC) and regulatory requirements (e.g., CMS, OSHA, HIPAA).
• Coordinate accreditation surveys, prepare required documentation, and act as the primary liaison with accrediting bodies.
• Prepare and submit required reports and documentation to regulatory agencies.
• Support the team in implementing quality initiatives and achieving accreditation readiness.

Patient Satisfaction

• Collect, manage, and analyze patient satisfaction surveys and other feedback mechanisms to identify trends, strengths, and areas for improvement.
• Design and implement strategies to improve patient satisfaction and experience, ensuring alignment with the practice’s mission and goals.
• Collaborate with leadership, clinical staff, and administrative teams to develop and roll out patient-centered initiatives.
• Develop and deliver training programs to enhance staff understanding of patient experience principles and the importance of compassionate care.
• Act as a resource for staff to address patient concerns and foster a positive patient-staff interaction environment.
• Identify and address process inefficiencies or barriers impacting the patient journey.
• Serve as the primary liaison for patient experience initiatives, working with patients, families, providers, and support staff to address concerns and promote satisfaction.
• Partner with marketing and communication teams to develop materials that educate patients about services and enhance their overall experience.

Data Analysis and Reporting

• Monitor, track, analyze, and report key performance indicators (KPIs) to leadership, highlighting successes, trends, and areas for improvement.
• Develop and present actionable recommendations

Travel Requirements

Travel to multiple locations throughout North and central Georgia as needed, with an estimated 50% of time spent on-site.

Requirements

Education and Experience

• Bachelor’s degree in healthcare administration, nursing, or a related field (Master’s preferred).
• Minimum of 5 years of experience in healthcare quality management, safety, or compliance, with at least 2 years in surgical or outpatient care settings.
• Certified Professional in Healthcare Quality (CPHQ) or equivalent certification preferred

Skills And Competencies

• Strong understanding of relevant accreditation processes (e.g., AAAHC, Joint Commission) and regulatory standards including but not limited to CMS Conditions for Coverage, HIPAA, and OSHA.
• Strong project management skills and ability to manage multiple priorities effectively.
• Excellent communication and interpersonal skills to effectively collaborate with diverse teams
• Excellent organizational, analytical, and problem-solving skills
• Demonstrated ability to implement quality improvement initiatives in multiple locations
• Ability to interpret data and translate findings into actionable strategies
• Proficiency in Microsoft Office Suite and familiarity with electronic health record (EHR) systems
• A strong commitment to understanding and improving the patient journey
• Valid Drivers License