The Quality Manager, is primarily responsible for daily management and coordination of departmental activities for the facilitation of a Performance Improvement (PI) program, which is a requirement of the Joint Commission (TJC), Centers for Medicare / Medicaid Services (CMS) and State of Hawaii Department of Health (SOH DOH). The PI Program is designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care and processes, and to resolve identified problems. This position is also responsible for collecting and screening information for the Medical Center and Medical Staff Department Performance Improvement indicators. The findings, conclusions, recommendations, actions taken, and evaluations of actions taken are documented and reported through channels established by the Medical Center and Medical Staff By-Laws.

The Quality Manager provides direction and oversight of the Infection Control Program  for three Maui Health System (MHS) facilities - Maui Memorial Medical Center, Kula Hospital, Lanai Community Hospital and associated clinical practice sites - manages the planning, development, implementation, evaluation/continuous improvement of an infection prevention and control program across entire care continuum. Through strategic planning, expert leadership and consultation, identifies and implements facility and system-wide infection control goals and objectives related to: surveillance, data analysis and reporting, infection prevention and control practices that eliminate potential infection hazards for patients, residents, clients, physicians, staff and visitors, appropriate selection and usage of products and equipment related to cleaning, antisepsis, disinfection, and sterilization, facility design and construction. Develops and coordinates implementation of educational programs designed to reduce or prevent infection. Provides infection prevention and control programs/services that add value and integrated with departmental, facility and organizational business and clinical goals and objectives.

This position also directs and oversees the Quality Data Analyst to support the medical centers performance improvement activities as well as medical staff quality oversight functions. Provides direct supervision to the Quality Management and Infection Control Department staff.

• This position is responsible for the PI program of MHS, which includes Medical Staff, Nursing, and Ancillary Clinical Departments, as well as a resource for non-clinical departments in their department specific PI indicators. Plans, organizes, updates and evaluates the Medical Centers PI plan, goals and objectives, and efforts to improve patient care and outcomes with the assistance of the Quality and Continuous Improvement Officer.


• Oversees the Performance Improvement and Infection Control programs.


• Assists with setting priorities for monitoring and evaluation activities.


• Manages the planning, development, implementation, evaluation/improvement of infection prevention and control services/programs that meet or exceed established standards/performance measures for quality, member/patient satisfaction, cost, employee quality of work life, physician/client department satisfaction, clinical outcomes and regulatory compliance.


•  Fosters a commitment and image throughout the hospital to excellence, caring, cooperation, and satisfying the expectations of all customers.


• Makes recommendations for improving care.


• Through surveillance activities, monitors, reports and develops applicable intervention for infection trends in the acute, long-term and ambulatory settings. Devlops, implements and improves systems, methods, processes to evaluate/improve performance and quality outcomes/measures for the infection prevention and control program.


• Spends a significant amount of time in providing technical assistance to the Quality Management staff, medical staff, supervisors, and department managers in completing sound evaluations of care or service.


• Creates processes to ensure the receipt of information via the problem identification/solving process from all Maui Memorial Medical Center categories (Medical Staff, Nursing, Administration, Ancillary, Risk Management, and patient care issues) and refers these problems or issues with recommendations for improvement if applicable to the specific department managers, medical staff committees, senior leaders, and the MMMC Quality Management Committee. Information Management systems such as MIDAS, Statit and other repositories are maintained with clinical reporting requirements and tracking of problems and the progress of their resolution for aggregation and review.


• Acts as a facilitator in the solving of problems identified in the Maui Memorial Medical Center problem solving process that may relate to more than one department, and may involve members of the various Medical Staff committees.


• Assists in interpreting accreditation and licensing standards to ensure the provision of quality and continuity of care.


• Maintains close communication with Medical Staff and supervisory personnel to identify non-compliance with established policies, procedures, standards, and recommends corrections to increase compliance.


• Collects data and prepares reports relating to patient satisfaction and disseminate data to departments with requests for improvement plans. Monitors complaints and tracks progress in improvement plans as it relates to lessening complaints.


• In conjunction with the Senior Director Quality, Risk & Patient Safety, prepares and submits monthly reports to the Medical Executive Committee (MEC) regarding medical departmental issues.


• Aggregates and trends accumulated monitored Medical Staff data specific to physician and provides the physician profiles to the Credentialing Committee for the purpose of reappointment.


• Aggregates and trends accumulated monitored hospital data specific to TJC requirements, CMS, national quality initiatives such as the American Heart Association - Get With The Guidelines CHF Program and other quality initiative as directed, identified areas of concern, and recommendations by the MMMC Quality Management Committee and the Senior Director Quality, Risk & Patient Safety.


• Annually updates the Medical Centers Performance Improvement Plan and appraises the Medical Centers Performance Improvement activities.