Patient Safety Quality Specialist, RN - Quality Assurance

This Patient Safety Quality Specialist directly reports to the Manager of Regulatory and Patient Safety. The Quality Specialist- Patient Safety is responsible for coordinating quality improvement and patient safety initiatives, providing guidance, education and assistance in the development, implementation, and measurement for assigned projects, quality improvement initiatives and patient safety events. Investigates and evaluates patient safety events for risk potential, loss minimization, and applicable recording and documentation. Analyzes risk factors data to develop evidence-based patient safety interventions and process improvement strategies. Provides consultation and support to teams or departments related to performance improvement initiatives, regulatory compliance and patient safety events. Participates in root cause analysis (RCA), failure mode and effects analysis (FMEA), and cluster investigations. Assists departments in identifying and correcting regulatory compliance issues and participates in preparatory activities for regulatory agencies. Research, collect and analyze internal and external data for decision making. Serve as subject matter expert regarding quality and patient safety initiatives, significant event management, and patient safety and risk reduction goals in alignment with the organization's strategic priorities.

Essential Duties:

• 1. Assessment - Assesses survey readiness and ensures all implementation of all applicable Patient Safety initiatives a. Evaluates prior survey deficiencies and current survey standards for compliance. b. Coordinators and provides leadership for survey readiness rounds and provides a rotating calendar of visits to units and hospital departments. c. Complies and disseminates information to the applicable hospital director on areas that require action to ensure compliance d. Ensures all quality and patient safety rounds identify opportunities to improve care and outcomes
• 2. Consultation - Provides consultation to individuals/departments concerning regulatory standards and assists with interpretation of new or revised standards; Recommends methods/actions to achieve regulatory compliance; Serves as a consultant for other projects as assigned.
• 3. Implementation - Implements corrective actions including but not limited to providing written responses to any RFI’s (Recommendation for improvement), or audit deficiencies related to regulatory compliance. Ensures that the applicable database is updated with any corrective action plans and follows up with the applicable department director regarding the proposed action plan.
• 4. Collaboration - Collaborates with all members of the healthcare team to promote an organized approach to the hospital’s survey process. Facilitates survey readiness teams. Cross-trained in the functions of Quality and Outcomes management and Peer Review processes to collaborate with department staff members and provide coverage as necessary.
• 5. Communication - Communicates any audit findings to the hospital leadership along with any proposed or implemented action plans. Attends any applicable hospital or medical staff committee meetings to communicate information on Survey Readiness
• 6. Education - Provides In-service to hospital and medical staff as appropriate to ensure survey preparedness.
• 7. Keeps updated on all regulations that pertain to hospital licensure and updates policies and procedures as necessary
• 8. Member of the policy and forms committee and works closely with the policy coordinator
• 9. Provides supervision and oversight for regulatory compliance staff ensuring a cohesive well informed team
• 10. Performs other duties as assigned.

Required Qualifications:

• Req Bachelor's degree Degree in Nursing.

• Req 1 year One or more years or more in an acute care setting (preferred with experience in licensing and accreditation).
• Req Experienced at least one facility-wide accreditation survey within the last three years.
• Req Working knowledge of TJC, CDPH, CMS accreditation and regulatory requirements.

Preferred Qualifications:

Required Licenses/Certifications:

• Req Registered Nurse - RN (CA Board of Registered Nursing)
• Req Certified Professional in Healthcare Quality - CPHQ (NAHQ) Certified Professional in Healthcare Quality (CPHQ) OR Certified Professional in Patient Safety (CCPS) certification within 2 years of hire.
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

The annual base salary range for this position is $110,240.00 - $181,896.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.