Supports initiatives to ensure high-quality clinical care, service excellence, and operational efficiency across the hospital and its service locations. Assists with Quality Assessment/Performance Improvement (QAPI) activities and aligns local efforts with system goals. Provides expertise in quality reporting, patient experience, safety, data analytics, and collaborates on infection prevention, regulatory compliance, and accreditation.
Key Responsibilities
- Assist in planning, tracking, and reporting QAPI activities.
- Support patient safety initiatives across the care continuum.
- Maintain compliance with regulatory requirements (ACHC, CMS, IDOH, Joint Commission, OSHA) and help ensure survey readiness.
- Supports the Physician Ongoing Professional Practice Evaluation (OPPE) process by Coordinating Clinical Indicators for Physician OPPE with Medical Staff Departments, along with IT system managers/administrators. Supports the Allied Health OPPE as needed.
- Coordinates and supports provider Focused Professional Practice Evaluation (FPPE) as directed.
- Prepare and submit mandatory reports; assist with corrective action plans.
- Collaborate with leadership to align local initiatives with system strategies for quality, patient experience, and cost-effective care.
- Collect, analyze, and present data to support performance improvement projects.
- Participate in committees and workgroups related to quality and safety.
Core Competencies
- Quality & Compliance: Apply continuous improvement principles and ensure adherence to standards.
- Customer Focus: Support service recovery and patient experience initiatives.
- Collaboration: Work effectively with multidisciplinary teams to achieve goals.
- Analytical Skills: Interpret data and identify trends for improvement.
Qualifications
- Education: Bachelor’s degree in Nursing or other health-care related field with at least five (5) years of related clinical experience. Master’s preferred.
- Experience: 2–3 years clinical or healthcare quality experience; highly proficient with data management, Lean Six Sigma, project management, and regulatory compliance.
- Licensure: RN preferred; CPHQ encouraged (must obtain within 2 years). Lean Six Sigma White Belt within 1 year; Yellow/Green Belt preferred within 2 years.
- Skills: Strong communication, problem-solving, data analysis, and proficiency in Microsoft Office.
