The position description is a guide to the critical duties and essential functions of the job, not an all\\-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.
**TITLE:** Quality Improvement Specialist
**JOB OVERVIEW:** Responsible for overseeing and enhancing the quality of care provided within the hospital for defined areas, populations, and/or clinical pathways. This role involves analyzing clinical processes, implementing quality improvement initiatives, and ensuring compliance with regulatory standards to enhance patient outcomes and safety. Serves as a consultant on the JTC, DOH, CMS and other regulatory requirements.
**DEPARTMENT:** Quality
**WORK HOURS:** Monday \\- Friday, typically 8:00 am \\- 4:30 pm with requirement for flexibility.
**REPORTS TO:** Manager, Quality Management
PREREQUISITES:
* Bachelor's degree in nursing OR other health care related field OR Bachelor of Medicine, Bachelor of Surgery (M.B.B.S.) required. Master's degree preferred.
* Current Registered Nurse or Registered Pharmacist license to practice in the State of Washington required. Those with M.B.B.S are not licensed in the State of Washington.
* Minimum three (3\\) years' clinical experience in an acute care health care setting required.
* Experience in use of electronic health record (EHR).
* Demonstrated skills for project management, problem solving, decision making, and change management.
* Experience in quality management and performance improvement role preferred.
* Certified Professional in Healthcare Quality (CPHQ) preferred.
QUALIFICATIONS:
* Solid understanding of systems thinking process management and performance improvement.
* Organizational and problem\\-solving ability and skills.
* Excellent facilitation skills, ability to create an environment that encourages open dialogue and collaborative problem\\-solving.
* Exhibits a genuine connection with frontline staff, offering clear, concise information and supportive feedback.
* Knowledge of group process, leadership skills, and ability to facilitate performance improvement teams.
* Proficiency in application of performance improvement tools and methodologies including aptitude for using QI data management software. Certifications or training in IHI Model for Improvement, Lean, Six Sigma, or Kaizen preferred.
* Ability to prioritize and manage multiple demands and maintain confidentiality of sensitive information.
* Knowledge of regulatory standards and interpretation including CMS, DOH and TJC.
* Ability to prepare effective oral and written reports and presentations to various groups including physicians, hospital leaders and staff.
* Proficiency in use of Windows® and MS Office Suites® applications particularly Word, Excel, Visio, and PowerPoint.
* Aptitude for navigating quality\\-related Internet sites and those of various data management vendors and support agencies.
UNIQUE PHYSICAL and MENTAL DEMANDS, ENVIRONMENT, AND WORKING CONDITIONS: See Generic Job Description for Administrative Partner
PERFORMANCE RESPONSIBILITIES:
* **Generic Job Functions:** See Generic Job Description for Administrative Partner
* **Essential Responsibilities and Competencies**
* Develop, implement, and oversee quality projects aimed at improving patient care, reducing errors, and enhancing hospital operations.
* Apply the IHI Model for Improvement to facilitate quality improvement teams.
* Demonstrate an understanding of team leader roles, group dynamics, and leadership strategies in the context of quality improvement teams.
* Support and guide improvement teams through various stages of the project management life cycle, from planning to execution.
* Assist physicians and managers in analyzing and interpreting data for decision\\-making and performance improvement.
* Lead or co\\-lead committees focused on quality, patient safety, and operational efficiency.
* Lead and participate in process redesign initiatives to streamline workflows.
* Promote a culture of safety and continuous improvement throughout the organization. Educate physicians, hospital leaders, and staff on quality management and performance improvement techniques and suggestions as needed.
* Ensure compliance with healthcare regulations, accreditation standards, and internal policies through audits and assessments. Abstract and collect data from electronic health records (EHR) to meet program monitoring requirements as needed.
* Develop data collection strategies based on research principles.
* Analyze and interpret clinical data to assess performance metrics and trends. Report variations in clinical care requiring immediate corrective actions.
* Prepare and present detailed reports on quality improvement outcomes for hospital leadership and regulatory bodies as scheduled or requested.
* Ensure that performance measures data are prepared and submitted in accordance with required timelines and standards.
* Support the Medical Staff through preparation of mandated ongoing performance measures data and peer review referrals.
* Build and maintain effective relationships with multidisciplinary teams to foster collaboration in quality improvement.
* Engage patients, families, and external stakeholders to incorporate their feedback into quality improvement efforts.
* Network with peers from other organizations and participate in relevant community outreach efforts and improvement collaboratives.
* Serve as a clinical expert to guide the development and implementation of programs and policies ensuring adherence to safety and quality standards.
* Stay current with emerging trends, best practices, and technologies in quality improvement and patient care. Apply knowledge from research and current literature to develop and implement improvement strategies.
* Benchmark hospital performance against internal and national/regional standards to identify opportunities for improvement.
* Navigate key online resources (e.g., AHRQ, TJC, CMS) for benchmarking and performance evaluation.
* Support the preparation and facilitation of regulatory and/or certification surveys.
* Assist in the development and review of clinical practice policies, procedures, order sets, and protocols in compliance with regulatory standards.
* Apply new insights to improve quality initiatives and contribute to ongoing organizational learning.
* Demonstrate awareness of cost containment strategies for quality improvement.
* Support the allocation and efficient use of resources to meet quality improvement goals and objectives.
* Perform other duties as assigned to meet program needs, including staff training and organizational support.
Revised: 4/25
Grade: NC\\-12
FLSA: E
CC:8714
**Job Qualifications:**
PREREQUISITES:
* Bachelor's degree in nursing OR other health care related field OR Bachelor of Medicine, Bachelor of Surgery (M.B.B.S.) required. Master's degree preferred.
* Current Registered Nurse or Registered Pharmacist license to practice in the State of Washington required. Those with M.B.B.S are not licensed in the State of Washington.
* Minimum three (3\\) years' clinical experience in an acute care health care setting required.
* Experience in use of electronic health record (EHR).
* Demonstrated skills for project management, problem solving, decision making, and change management.
* Experience in quality management and performance improvement role preferred.
* Certified Professional in Healthcare Quality (CPHQ) preferred.
QUALIFICATIONS:
* Solid understanding of systems thinking process management and performance improvement.
* Organizational and problem\\-solving ability and skills.
* Excellent facilitation skills, ability to create an environment that encourages open dialogue and collaborative problem\\-solving.
* Exhibits a genuine connection with frontline staff, offering clear, concise information and supportive feedback.
* Knowledge of group process, leadership skills, and ability to facilitate performance improvement teams.
* Proficiency in application of performance improvement tools and methodologies including aptitude for using QI data management software. Certifications or training in IHI Model for Improvement, Lean, Six Sigma, or Kaizen preferred.
* Ability to prioritize and manage multiple demands and maintain confidentiality of sensitive information.
* Knowledge of regulatory standards and interpretation including CMS, DOH and TJC.
* Ability to prepare effective oral and written reports and presentations to various groups including physicians, hospital leaders and staff.
* Proficiency in use of Windows® and MS Office Suites® applications particularly Word, Excel, Visio, and PowerPoint.
* Aptitude for navigating quality\\-related Internet sites and those of various data management vendors and support agencies.
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