Quality Patient Safety Specialist - Full Time

Patient Safety

• Support the organization's patient safety program and promote a culture of safety and continuous improvement.
• Review patient safety events, incident reports, and near misses for trends, contributing factors, and opportunities for improvement.
• Assist with event investigation, including information gathering, interviews, documentation review, and identification of contributing factors.
• Support Root Cause Analyses (RCA), Action Plans, and other patient safety improvement methodologies as assigned.
• Assist with implementation and monitoring of patient safety initiatives and corrective actions.
• Support the organization's Good Catch/near-miss recognition and patient safety reporting programs.
• Assist with patient safety huddles, safety rounding, and other proactive safety activities.
• Escalate significant patient safety concerns to the appropriate leader promptly.

Quality & Performance Improvement

• Monitor and analyze quality and performance improvement data to identify trends, opportunities for improvement, and areas of risk.
• Assist with the development, implementation, and monitoring of quality improvement initiatives and action plans.
• Prepare quality reports, dashboards, presentations, and other materials for leadership and committee review.
• Assist departments in establishing measurable goals and monitoring progress toward identified quality objectives.
• Participate in performance improvement teams and interdisciplinary quality initiatives.
• Assist with review and trending of hospital quality indicators, including clinical outcomes, process measures, patient experience measures, and other organizational performance metrics.
• Identify trends and communicate significant findings to appropriate leadership.

Regulatory & Accreditation

• Assist with organizational readiness for regulatory and accreditation surveys, including CMS, Department of Health, accrediting bodies and other applicable organizations.
• Monitor regulatory and accreditation requirements and communicate relevant changes to leadership.
• Assist with regulatory gap analyses and development of corrective action plans.
• Track findings, action plans, responsible parties, and completion dates.
• Participate in tracer activities, environmental rounds, mock surveys, and other readiness activities.
• Assist with preparation of documentation and evidence of compliance for regulatory and accreditation reviews.

Data & Reporting

• Collect, validate, analyze, and trend quality and patient safety data.
• Maintain accurate quality and patient safety databases, trackers, and reporting systems.
• Develop reports and presentations for quality committees, leadership, and other stakeholders.
• Assist with identification of statistically or operationally significant trends.
• Ensure data is reported accurately, timely, and in accordance with organizational and regulatory requirements.
• Support benchmarking activities and comparison of organizational performance against applicable national, state, regulatory, and peer benchmarks.

Committees & Leadership Support

• Support the work of Quality, Patient Safety, Performance Improvement, and other related committees.
• Prepare agendas, reports, data, and other materials as assigned.
• Participate in committee meetings and document follow-up items when appropriate.
• Track committee action items and ensure follow-up with responsible individuals.
• Assist leadership with preparation of Board and executive-level quality and patient safety reports.

Education & Staff Support

• Serve as a resource to leaders and staff regarding quality improvement and patient safety processes.
• Assist with development and delivery of education related to quality, patient safety, regulatory requirements, and performance improvement.
• Promote consistent understanding and application of quality and patient safety practices.
• Assist with Just Culture, patient safety, event reporting, RCA, and other quality-related education as assigned.

Other Duties

• Maintain confidentiality of patient, employee, medical staff, and organizational information.
• Demonstrate professional judgment and appropriately escalate concerns involving patient safety, quality, regulatory compliance, or organizational risk.
• Participate in organizational initiatives and special projects as assigned.
• Maintain current knowledge of applicable healthcare regulations, accreditation standards, quality measures, and patient safety practices.
• Perform other duties as assigned by the IRMC Director of Quality and MH Patient Safety Lead.