Quality and Patient Safety Specialist

Requirements

• 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
• 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
• 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. Responsibili

Benefits

Additional Information

The Quality and Patient Safety Specialist supports the organization in advancing high‑reliability and a culture of safety. Under general supervision, this role provides leadership, guidance, and subject‑matter expertise to clinical and operational teams to ensure compliance with policies, accreditation standards, and patient safety requirements. In general, the specialist oversees and/or facilitates quality and patient safety activities, including safety event review and analysis, performance improvement initiatives, Comprehensive Systematic Analyses, and physician peer review coordination. Education: Bachelor's degree in nursing; Master's degree preferred

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