Quality & Patient Safety Specialist

Works as independent, subject matter expert in the Quality and Patient Safety field; to oversee and support assigned sections of the Quality and Patient Safety Program at Exeter Hospital. Supports the Quality Management System to meet Regulatory/Accreditation Requirements and Best Practices in Quality and Patient Safety.

Requirements:

• 3-5 years’ experience in a Medical Setting
• Bachelor’s Degree in directly related
• RN Degree and Certification in Quality (CPHQ) and/or Patient Safety (CPPS) within 24 months of hire
• Strong analytical skills and Strong communication skills
• Training/certification in Lean/process improvement w/in 18 mo. of hire
• Master’s degree in Nursing or Healthcare field preferred

Major Responsibilities:

1. Quality Reporting - Oversees collection, analysis and reporting of the key measures required for incentive payment, regulatory and accreditation program compliance; educates team members re: the technical specifications of measurement and quality reporting to ensure organization-wide performance is at the highest level possible for optimal reimbursement and bonus payments.
2. Regulatory/Accreditation Compliance - Oversees collection and analysis of regulatory/accreditation/certification data and collaborates with departments and teams to facilitate system and process improvements based on performance and benchmarks. Leads cross-functional teams to facilitate the improvement of care processes and best practices to meet compliance standards
3. Data Management- Selects, defines and obtains process and outcome data for departments to monitor and understand quality performance, set improvement goals and evaluate the results of improvement efforts. Builds scorecards and reports, and provides information related to individual staff and provider activities to support peer review, Quality Improvement Priorities and accreditation requirements. Creates and uses statistical charts and other industry tools within the data analysis process. Prepares and presents reports for organizational leadership including senior leaders, Medical Staff leaders & program directors that meet regulatory & accreditation requirements & support ongoing monitoring of performance & related improvement efforts.
4. Culture of Safety- Facilitates the Culture of Safety survey, safety event reporting and event analysis and uses those inputs to identify opportunities for improvement, in collaboration with operational leaders and the Lean team. Collaborates with department staff to identify education, training, or process changes which will have a positive impact on the safety culture. Conducts education and training programs for frontline leaders and staff re: a culture of safety and the Framework for Excellence.
5. Patient Safety - Leads or participates in all aspects of the Patient Safety Program including corrective & preventive action, root cause analysis (RCA), proactive risk assessment (FMEA), safety data review and analysis. Actively participates in frontline efforts to mitigate risks to patients and ensure safe and effective care.
6. Subject Expert - Serves as a subject expert in quality reporting, data management, patient safety and process improvement on assigned unit, department and program teams including interpretation of technical measurement specifications and selection and application of data and improvement tools and approaches.
7. Project Management- Acquires and maintains knowledge and skills in project management techniques and tools. Actively participates in assigned projects; Leads projects with team members as requested. Successfully monitors and reports project data. Evaluates the success of assigned projects. Utilizes appropriate tools throughout data collection phase of projects. Completes/participates in at least one QI/PS project per year.
8. Peer Review - Works directly with medical staff leaders, medical directors, Risk Management and frontline providers to support an effective medical staff peer review program. This may include case reviews, data analysis and reporting and provider education and training aimed at ensuring individual providers and groups are employing best practices to achieve care that is safe, effective, efficient, timely, equitable and patient-centered