Quality, Safety & Performance Improvement Specialist

Beth Israel Lahey Health•Newburyport, MA

1d•$90,000 - $135,000•Onsite

About The Position

Reporting to the Director of Quality & Safety, the Quality, Safety & Performance Improvement Specialist supports a comprehensive quality, patient safety, regulatory, and patient experience program at Anna Jaques Hospital. Working with clinical, operational, and administrative leaders, the Specialist coordinates, facilitates, monitors, and evaluates activities involving quality and performance improvement, patient safety, grievances, regulatory compliance, accreditation readiness, and patient experience. The role functions as a Quality Department generalist and internal consultant to departments throughout the organization. It supports the collection, analysis, interpretation, and reporting of quality and safety data; facilitates improvement initiatives; assists with regulatory readiness; and collaborates with multidisciplinary teams to improve clinical outcomes and patient experience, reduce organizational risk, and foster a culture of safety, service excellence, accountability, transparency, patient-centered care, and continuous improvement. The position requires frequent sitting, standing, walking, computer use, and participation in meetings throughout the organization. The Specialist must travel throughout hospital departments and affiliated locations and participate in audits, surveys, investigations, and committee activities as needed. Work takes place in office and healthcare environments, with frequent interaction with physicians, staff, patients, families, hospital leaders, and external regulatory representatives. Occasional schedule flexibility may be required to support investigations, surveys, meetings, or organizational priorities. All staff must be vaccinated against influenza as a condition of employment.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, Public Health, Health Sciences, Quality Management, or a related healthcare field.
Acute care hospital experience.
State of Massachusetts Registered Nurse (RN) licensure.
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, collaboration, written communication, 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, travel throughout hospital departments and affiliated locations, and participation in audits, surveys, investigations, and committee activities.

Nice To Haves

Master’s degree in Nursing, Healthcare Administration, Public Health, Business Administration, or a related field.
One to three years of experience in healthcare quality, patient safety, performance improvement, risk management, patient relations, regulatory compliance, accreditation, or related healthcare operations.
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

Support hospital-wide quality improvement and performance improvement initiatives aligned with organizational goals, strategic priorities, and regulatory requirements.
Help departments identify improvement opportunities through data analysis, benchmarking, audits, observations, and performance monitoring.
Facilitate improvement projects using methodologies such as PDSA, Lean, Root Cause Analysis, and Failure Mode and Effects Analysis.
Collaborate with clinical and operational leaders to develop, implement, and monitor corrective action plans and improvement initiatives.
Support QAP activities, documentation, reporting, and performance monitoring; participate in quality committees, multidisciplinary workgroups, and performance improvement teams.
Monitor quality metrics and performance indicators and report findings to leaders and committees.
Support implementation and coordination of the hospital’s patient safety program; review safety events, near misses, and incident reports and ensure appropriate follow-up and escalation.
Conduct or facilitate event investigations, apparent cause analyses, and root cause analyses as appropriate; track and trend safety events and work with leaders and frontline staff on corrective and preventive actions.
Support High Reliability Organization initiatives and safety culture, patient safety education, communication, and awareness programs; prepare related reports and presentations.
Coordinate investigation, tracking, and resolution of patient complaints and grievances in accordance with applicable requirements; collaborate with patients, families, providers, managers, and staff on timely resolution.
Draft grievance correspondence, maintain grievance records, monitor complaint and feedback trends, and identify opportunities to improve patient experience, communication, and service recovery.
Support patient experience and patient-centered care initiatives and monitor and report measures including Press Ganey and HCAHPS.
Support readiness for regulatory, accreditation, and licensing surveys; participate in mock surveys, tracers, audits, and compliance assessments.
Help departments address regulatory findings and implement corrective action plans; monitor compliance with applicable standards, regulations, and organizational policies.
Maintain documentation and assist with survey preparation, coordination, response activities, and follow-up; serve as an internal resource on quality, patient safety, patient rights, and regulatory requirements.
Collect, validate, analyze, and interpret quality, safety, patient experience, grievance, and performance improvement data.
Develop reports, dashboards, scorecards, summaries, and presentations; support internal and external quality reporting and maintain quality databases, reporting systems, and performance monitoring tools.
Identify trends, performance gaps, risks, and improvement opportunities through data analysis and benchmarking; prepare reports for leadership, committees, regulators, and external quality programs.
Provide departmental consultation and support on quality improvement, patient safety, patient experience, grievance management, and regulatory compliance.
Assist in developing and delivering education on quality, safety, accreditation, performance improvement, and patient experience; support committees with meeting preparation, reporting, follow-up, and documentation.
Facilitate collaboration among clinical and operational departments, participate in special projects and organizational initiatives, and perform other duties as requested or required.