Quality Improvement Specialist Full Time Days

BASIC PURPOSE OF THE JOB

The Quality Improvement Specialist plays a pivotal role in advancing patient safety, regulatory compliance, and performance excellence across the hospital. This role leverages data analytics, process improvement methodologies, and cross-functional, interdisciplinary collaboration to drive sustainable improvements in care delivery. The Specialist will apply the NAHQ Healthcare Quality Competency Framework to guide initiatives and foster a culture of high reliability. This role maintains the highest level of confidentiality of all patient information reviewed. Through quality team integration, it promotes effective communication with all ETCH department employees, patients, visitors, and other personnel within and outside of the organization. Assists in managing the organization-wide occurrence (event) monitoring program and other nationally recognized quality registries and networks as assigned. Represents ETCH at national quality conferences as assigned.

REPORTS TO

• Manager-Quality, Patient Safety, and Regulatory Compliance

JOB REQUIREMENTS

Supervisory Responsibilities: NO

Minimum Education: Master's Degree OR Bachelors with Commitment to Achieve Master's Degree within 2 years of Hire

Degree: Degree in Nursing, Statistics, Public Health, Health Information Management, Biological Sciences, or other related field

License/Certification Preferred: Certified Professional in Patient Safety (CPPS) and/or Certified Professional in Healthcare Quality (CPHQ) preferred

Minimum Work Experience: Minimum 3 years of experience in healthcare quality, patient safety, or performance improvement

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Proficiency in data analysis tools (e.g., Excel, Tableau, Power BI)
• Proficiency with EHR systems (Meditech, EPIC)
• Strong communication, facilitation, and project management skills
• Self-directed with strong time management skills
• Demonstrates the ability to work independently while meeting multiple deadlines
• Proactive in managing workload and priorities without close supervision
• Exhibits accountability and reliability in completing assigned tasks

DUTIES AND RESPONSIBILITIES

Quality Leadership & Integration

• Champion quality improvement initiatives aligned with hospital strategic goals
• Facilitate interdisciplinary teams to embed systemic learning and accountability through the organization's Quality and Patient Safety Plan
• Support leadership in translating vision into measurable quality outcomes through managerial oversight

Performance & Process Improvement

• Lead root cause analyses and failure mode assessments (e.g., RCA, FMEA)
• Apply Lean, Six Sigma, and PDSA cycles to optimize clinical and operational workflows
• Develop and monitor action plans for performance improvement projects

Population Health & Care Transitions

• Analyze care transition data to identify gaps in continuity and outcomes
• Collaborate with case management and community partners to reduce readmissions
• Support initiatives targeting vulnerable populations and health equity

Health Data Analytics

• Extract, validate, and interpret clinical and operational data from EHRs and dashboards
• Develop visualizations and reports to communicate trends and opportunities
• Monitor and manage key performance indicators (KPIs) and regulatory metrics

Patient Safety

• Investigate safety events and near misses using Just Culture principles
• Promote proactive risk mitigation strategies and safety huddles
• Support compliance with National Patient Safety Goals and internal safety alerts

Regulatory & Accreditation

• Ensure readiness for Joint Commission, CMS, and state inspections
• Maintain documentation and evidence for standards compliance
• Assist departments in interpreting and applying regulatory requirements

Quality Review & Accountability

• Conduct audits and peer reviews to assess adherence to protocols
• Track corrective actions and verify sustained improvements
• Present findings to leadership and quality committees

Professional Engagement

• Participate in hospital-wide quality councils and learning collaboratives
• Mentor staff on quality principles and improvement tools
• Maintain CPHQ or CPPS certification and engage in ongoing professional development

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Light lifting, pushing and pulling is required for 10-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending and reaching is required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.