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, promotes effective communication with all Dolly Children's 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 Dolly Children's at national quality conferences as assigned.

Reports to:  Manager - Quality Management & Patient Safety

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

QUALIFICATIONS

• Bachelor’s degree in nursing, Healthcare Administration, Public Health, or related field (Master’s preferred) and 3 years of experience in healthcare quality, patient safety, or performance improvement or Associate degree (or equivalent) plus at least five years of healthcare experience (also including clinical rotations).
• Certified Professional in Patient Safety (CPPS) and/or Certified Professional in Healthcare Quality (CPHQ) within 12 months of hire
• Proficiency in data analysis tools (e.g., Excel, Tableau, Power BI) and EHR systems
• Strong communication, facilitation, and project management skills

Performance Metrics

• Timely completion of improvement projects
• Reduction in adverse events and readmissions
• Compliance with regulatory standards
• Staff engagement in quality initiatives

Physical/Mental Requirements:

• Light lifting, pushing, pulling is required for 10-20lbs occasionally and frequent moving of objects of less than 10lbs is required.   Frequent sitting with some walking, standing, squatting, bending and reaching is required.   Keyboard/computer use and/or repetitive motions may be required.
• Must be able to handle multiple priorities
• Independent discretion/decision making
• Works in close proximity to others and/or in a distracting environment

Come work where you can make a difference everyday.