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Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Quality & Patient Safety

Job Family

Professional

Work Shift

Days (United States of America)

Summary

Serves as an expert resource to advance Quality and Patient Safety (PS). Supports the management of quality and performance improvement for the organization and its Medical Staff through participation in and coordination of activities related to the acquisition, aggregation, and analysis of relevant data and its use toward improvement of clinical and work processes. Assists in overseeing constant preparedness for Joint Commission, CMS, and other regulatory inspections. Develops, manages, and coordinates the quality, evidence-based care of patients. Strives to ensure evidence-based medicine is used the treatment of patients. Provides education and leadership on patient floors to drive quality metrics in disease specific areas.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Serves as an educator on the patient floors to help drive quality of care and CMS/Leapfrog metrics
• Works with Team Leaders, Facilitators, and Members to provide ongoing education related to process, data analysis and tools
• Resource in providing monthly reports to the Quality Council/Patient Safety Team, Medical Executive Committee (MEC) and Board of Trustees on Performance Improvement, Patient Safety and Regulatory
• Coordinates Hospital wide PI/PS/Regulatory meetings as assigned
• Identifies and mitigates patient safety risks and coaches staff/leaders and physicians in safe practices
• Uses project management tools as needed to interpret data
• Applies lean tools and processes to reduce waste in areas of cost, inventory, labor, and distance
• Coordinates Root Cause Analyses and Failure Mode and Effect Analyses as assigned
• Demonstrates knowledge of current Joint Commission and CMS standards
• Assists with the tri-annual Joint Commission survey within the organization and CMS and DHSR surveys
• Stays current with CMS and other regulatory standards related to the Core Measures
• Assists multidisciplinary team in developing, implementing, and monitoring systems to ensure transitions of care from acute inpatient phase through follow-up out-patient care
• Participates in and supports the Joint Commission DSC process and performance measure compliance
• Evaluates interdisciplinary care processes ensuring consistency in the standards of care and practice
• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Bachelor of Science in Nursing required
• Current licensure in North Carolina as a Registered Nurse or Compact state licensure
• Nurse Practitioner NP preferred

Work Experience: 

• 2 years’ experience in working with Quality/Patient Safety and Regulatory, Quality Process and/or Data Analysis

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language
• Knowledge of PI methodologies, Joint Commission and CMS standards, and patient safety issues
• Knowledge of quality planning, cost of quality, and importance of documentation
• Knowledge of basic statistics, distributions, probability, and measurement scale
• Skills with the audit process to include audit types as well as audit roles and responsibilities
• Skills in working with teams to include team building techniques and understanding team roles and responsibilities
• Ability to collect, aggregate and review data. Experience with regression and correlation, hypothesis testing, design of experiments (DOE) preferred

Physical Requirements: 

• Ability to move throughout the Health System
• Visual acuity for reviewing data and reports and observing process flows
• Audiological acuity for monitoring group discussions and interactions
• Verbal ability is required to effectively express ideas and views to staff
• No anticipated occupational exposures to bloodborne pathogens or body fluids
• Must be able to lift 35 pounds

#CFVH-2026

Required Licenses and Certifications

RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity