Clinical Quality, Safety & Performance Improvement Specialist (RN Preferred)
About The Position
The Clinical Quality, Safety & Performance Improvement Specialist supports hospital-wide initiatives focused on quality improvement, patient safety, regulatory compliance, accreditation readiness, and patient experience. Working with nursing, medical staff, and operational leaders, the specialist uses data, performance improvement methodologies, and clinical expertise to improve patient outcomes, strengthen the safety culture, enhance patient experience, and ensure regulatory compliance. The position supports quality and safety initiatives, event reviews and investigations, corrective actions, patient complaint and grievance resolution, accreditation readiness, reporting, and education. The specialist serves as a resource to nursing and interdisciplinary teams and facilitates collaboration across clinical and operational groups. Work is performed in a combination of office and healthcare environments, with frequent interaction with physicians, staff, patients, families, hospital leaders, and external regulatory representatives. The role requires travel throughout hospital departments and affiliated locations and participation in audits, surveys, investigations, and committee activities. Occasional schedule flexibility may be required. The organization requires staff to be vaccinated against influenza as a condition of employment.
Requirements
- State of Massachusetts Registered Nurse (RN) licensure is required; RN is preferred in the job title.
- Bachelor's degree in Nursing, Healthcare Administration, Public Health, Health Sciences, Quality Management, or a related healthcare field is required.
- Minimum of 1–3 years of experience in healthcare quality, patient safety, performance improvement, risk management, patient relations, regulatory compliance, accreditation, or related healthcare operations is listed as preferred.
- Acute care hospital experience is required.
- Knowledge of healthcare quality management principles and performance improvement methodologies.
- Working knowledge of patient safety, risk reduction, and quality improvement tools and techniques.
- Knowledge of CMS Conditions of Participation, The Joint Commission standards, Massachusetts Department of Public Health regulations, and other applicable regulatory requirements.
- Understanding of Quality Assessment and Performance Improvement (QAPI) principles and practices.
- Strong analytical, organizational, and problem-solving skills.
- Ability to interpret, analyze, and communicate complex performance and quality data.
- Excellent interpersonal, relationship-building, and collaboration skills.
- Strong written and verbal communication skills.
- Ability to facilitate multidisciplinary teams and lead improvement projects.
- Ability to manage multiple priorities and meet deadlines in a fast-paced healthcare environment.
- Proficiency in Microsoft Office applications, including Excel, Word, PowerPoint, and reporting tools.
- Ability to maintain confidentiality and exercise sound professional judgment.
- Consistently promote the organization's WE CARE values: Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity.
- Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment.
- Ability to meet the physical and environmental demands of frequent sitting, standing, walking, computer use, meetings, and travel throughout hospital departments and affiliated locations.
Nice To Haves
- Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or a related field.
- Experience supporting quality improvement, regulatory readiness, patient safety, or patient experience initiatives.
- Certified Professional in Healthcare Quality (CPHQ).
- Certified Professional in Patient Safety (CPPS).
- Lean, Six Sigma, or related Performance Improvement certification.
Responsibilities
- Partner with nursing, physician, and operational leaders to improve patient outcomes, quality measures, and clinical performance.
- Lead and support performance improvement initiatives using evidence-based methodologies such as PDSA, Lean, RCA, and FMEA.
- Analyze quality and clinical data to identify trends, risks, and opportunities for improvement.
- Support the hospital's patient safety program through event review, investigation, and follow-up.
- Collaborate with frontline staff and leaders to implement corrective actions that reduce harm and improve safety outcomes.
- Promote a culture of safety and High Reliability Organization (HRO) principles.
- Coordinate review and resolution of patient complaints and grievances while ensuring regulatory compliance.
- Support accreditation readiness activities, including audits, tracers, surveys, and compliance monitoring.
- Partner with clinical teams to improve patient experience, service recovery, and patient-centered care.
- Develop and present quality, safety, patient experience, and performance reports for leadership and committees.
- Provide education, coaching, and consultation to clinical teams regarding quality, safety, and regulatory requirements.
- Serve as a trusted resource to nursing and interdisciplinary teams on quality improvement and patient safety best practices.
- Travel throughout hospital departments and affiliated locations and participate in audits, surveys, investigations, and committee activities as needed.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
