Responsible for evidence-based care and clinical excellence by using the techniques of system design, reengineering, project management, patient safety, quality improvement, outcomes measurement, and statistical analysis to increase compliance rates as measured by nationally standardized benchmarks and definitions and corporate requirements. This includes: project management, training, data management, and activities to support regulatory compliance.


Principal Accountabilities:


1. Project Management: Facilitates/assists with quality improvement projects for teams and/or departments as assigned. Engages in activities to identify potential patient safety risks and initiatives to improve patient safety.
2. Training: Provides in-service training in patient safety principles/practices, quality management, performance improvement techniques and organizational operating procedure standards. Participates in Shared Governance Councils, Hospital Quality/Patient Safety meetings providing guidance and instruction in PI Techniques
3. Data Management: Collects, compiles, analyzes and reports quality data. Monitors effectiveness and adherence with corrective action plans and reports findings to the Director of Quality and Patient Safety or designee.
4. Regulatory Compliance: Participates in activities to monitor and ensure ongoing compliance with quality and regulatory standards such Joint Commission, State Department of Health, Centers for Medicare and Medicaid, payers and other agencies. Provides support during accreditation/regulatory surveys.
5. Other related duties as assigned.