Education:

Bachelor's degree in nursing; Master's degree preferred

Experience:

• At least 3 years' experience in a Joint Commission accredited hospital or other similar healthcare environment.
• At least 3 years' experience in accreditation/regulatory/certification coordination and preparedness, performance improvement or patient safety preferred.
• Experience with quality improvement, patient safety, healthcare regulatory compliance, and action planning.

Licensures and Certifications:

• Licensed Registered Nurse
• Certification in Patient Safety (CPPS) within 1 year and/or Certification in Healthcare Quality (CPHQ) within 2 years

Skills:

• Excellent interpersonal communication skills necessary to interact effectively with a wide variety of constituents.
• Excellent organization, verbal and written communication, problem solving and team facilitation skills.
• Skill in using a computer and a variety of personal productivity applications (Excel, PowerPoint, Outlook, etc.)
• Ability to exercise judgment in interpreting and applying standards of care, regulations, hospital policies, procedures, and processes.
• Ability to review, analyze and develop clinical summaries of patient charts and identify the need for physician peer review.
• Knowledge of medical terminology and navigation of electronic medical record.
• Skill in conducting investigations, including chart reviews and timelines, in order to address patient safety and quality issues. 
• Demonstrated working knowledge of eCQMs and externally reported quality measures, including CMS, Leapfrog, and other reputational and governing bodies, and supports accurate abstraction, validation, and submission processes
• Skill in providing consultation, coaching, and support to hospital staff
• Ability to deliver educational and training materials to clinical and support staff teams.
• Ability to facilitate improvement, specifically Comprehensive Systematic Analyses which may include RCAs, ACAs and FMEAs.
• Familiar with the Model for Improvement – PDSA.
• Knowledge of process improvement principles and ability to lead teams toward fixing reoccurring issues.
• Ability to gather, create reports, interpret and analyze data.

Principal Duties and Responsibilities:

• Participates and assists during onsite TJC and CMS survey site visits.
• Conducts orientation of new employees and nursing related to quality and patient safety.  Provides on-going staff education and support.
• Regularly rounds on assigned units/departments ensuring a collaborative relationship with those areas’ leaders and staff
• Reviews safety events from the incident reporting system as assigned and triages appropriately for potentially compensable events and reportable events. Ensures follow-up is appropriate and conducts follow-up as necessary. Prepares analysis of events and action items
• Facilitates Comprehensive Systematic Analyses as designated by the Risk Prioritization Matrix and submits reports as required to regulatory agencies. Ensures thorough analyses are conducted and include appropriate corrective actions and measures of success. Tracks completion of corrective action and escalates when needed 
• Partners and collaborates with clinical, operational, and data teams to monitor trends, identify variation and improvement opportunities and drive sustainable improvement in outcome, process, and patient experience measures. Consults with leadership to follow up on action items required to improve processes identified through analysis and investigation. 
• Leads analysis and improvement of key quality outcomes across acute care settings, translating performance data into targeted improvement strategies that align with organizational priorities and regulatory requirements
• Supports governance and leadership reporting, preparing clear, actionable quality performance summaries for committees, executives, and boards.
• Facilitates assigned committees, task forces, or improvement teams.
• Effectively leads through influence in a matrixed environment, facilitating collaboration with operational and clinical leaders to drive alignment, accountability, and measurable quality improvement
• Conducts improvement activities in collaboration with the Performance Improvement Team and independently using tools such as: IHI Model for Improvement, PDSA, A3.  
• Makes appropriate decisions about the need for physician peer review and facilitates timely physician peer review. Responsibilities may include setting the agenda; taking minutes; preparing, assigning, and tracking cases/indicators; communicating findings/recommendations to relevant committees and/or the Medical Board.
• Serves as a liaison between Nursing and Medical Staff to create alignment where possible
• Provides cross-coverage for other functions of Quality and Patient Safety Specialists.

All Roles Must Follow GBMC Values:

Respect

• Treats others with fairness, kindness, and respect for personal dignity and privacy

• Listens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

• Meets and/or exceeds customer expectations
• Actively pursues learning and self development
• Pays attention to detail; follows through

Accountability

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

Teamwork

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

Ethical Behavior

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

• Embraces change and improvement in the work environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.