Under the direction of the Director of Quality Improvement, the Quality Improvement Specialist is responsible for implementing the organization's Performance Improvement plan. Primary responsibility for designing and implementing accurate data collection and audit strategies to meet the goals of performance improvement projects. Responsible for meaningful aggregation of data using appropriate performance improvement tools and methodologies and implementing and facilitating appropriate interventions to meet quality goals. Promotes a culture that is positive, that values individual strengths, and is committed to optimal patient care, and compliance with regulatory standards.

Key responsibilities include:

• Primary responsibility for data abstraction of all Stroke cases and compilation of reports using Get with the Guidelines Stroke Database. Facilitates the Stroke Committee performance improvement initiatives and facilitates ongoing compliance with New York State and Joint Commission Stroke requirements. Attend Code Gray events and assist in debriefing post event as required.
• Facilitates and conducts monthly pressure injury and restraint prevalence studies in accordance with the National Database of Nursing Quality Indicators methodology. Analyzes prevalence study results and identify improvement opportunities.
• Conducts focused audits as directed which may include direct observation of clinical staff, review of medical record information, or patient interview.
• Facilitate and meet analytic needs for improvement projects/initiatives. Supports the department in development of problem charter and selection of the best tools for data analysis. Working knowledge of basic statistical concepts and improvement tools and techniques.
• Lead and/or facilitate complex multidisciplinary improvement teams as needed to achieve quality and performance improvement goals.
• Responsible for data collection, measurement, and analysis for organizational, federal and state quality metrics.
• Conduct focused audits of compliance with regulatory standards (CMS, TJC, and NYS) as directed.
• Create and present data needed for evaluation and appropriate action by committees, leadership, and quality improvement teams.
• Represents the organization within and external to the community when required.
• Assist in improving patient experience through analysis of data and implementation of initiatives to improve performance.

Requirements:

• Bachelor's Degree or commensurate experience required.
• Registered Nurse in New York State required
• Master's Degree in Healthcare specialty preferred
• Current certification as CPHQ preferred.
• Expertise in Microsoft office products including PowerPoint and Microsoft Excel.
• Familiarity with health care clinical operations and processes in an acute care hospital setting.
• Familiarity with regulatory requirements as related to hospital setting.

Other Requirements:

• The employee must regularly lift, carry or push/pull less than 10 pounds, frequently lift, carry or push/pull less than 10 pounds, and occasionally lift, carry or push/pull up to 10 pounds.
• While performing the duties of this Job, the employee is regularly required to perform activities that require fine motor skills. The employee is frequently required to do repetitive motion, hear, reach, sit, and speak. The employee is occasionally required to walk.
• Specific vision abilities required by this job include color vision, far vision, and near vision.
• The noise level in the work environment is usually quiet.
• Interactions with a variety of disciplines and patient populations

Salary: $120K-$130K

Saint Joseph's Medical Center is an equal opportunity employer.