Quality and Safety Specialist III (L+M)

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Under the direction of the Quality & Safety department leadership, the Quality & Safety Specialist is responsible and accountable for facilitating improvements in clinical and operational performance in delivery network and system-wide patient safety and clinical quality. Collaborating with frontline management, staff, and clinicians, the team uses safety science and performance improvement methodologies to evaluate and improve clinical processes of care by reducing variation and driving standardization according to best practices.

EEO/AA/Disability/Veteran

• 1. Leads, facilitates and executes quality and safety projects to improve performance across YNHHS.
• 2. Supports the Safety and Quality Department in meeting goals. Identifies key process indicators (KPI) and uses KPI to determine progress and barriers to achieving team goals.
• 3. Utilizes knowledge of patient safety science, IHI model for improvement, Lean, or other validated methodologies for process improvement to lead, facilitate, manage, and report on quality and patient safety initiatives while teaching and supporting others in using appropriate quality and safety tools and methodologies.
• 4. Classifies safety events and determines appropriate follow-up actions.
• 5. Influences and communicates with all clinical and operational management levels concerning quality and safety program goals and progress.
• 6. Practices, trains, and provides mentorship on the philosophy, methodologies, application, and tools of safety science and performance improvement.
• 7. Independently coordinates local and system-wide initiatives to implement corrective actions to mitigate risk of recurrence.
• 8. Stays abreast of changes that impact system-wide performance in reported measures including, but not limited to Centers for Medicare Services (CMS) and QualityNet, Vizient, Agency for Healthcare Quality (AHRQ), LeapFrog, US News & World Report, and clinical registries.
• 9. Supports Q&S operations by utilizing appropriate benchmarking and performance resources (i.e., Centers for Medicare Services (CMS) and QualityNet, Vizient, Agency for Healthcare Quality (AHRQ), LeapFrog, US News & World Report, and clinical registries) to formulate integrated clinical and operational data analyses.
• 10. Supports operations by utilizing appropriate information systems and leads the development of integrated clinical and operational data analyses.
• 11. Serves as a content expert and partners with ITS in the development of dashboards and reports and acts as a coach to executives and clinical leaders at all levels in developing, analyzing, and understanding key critical safety and quality measures.
• 12. Independently conducts periodic gap analyses and action plan development to ensure alignment with national patient safety and clinical quality initiatives.
• 13. Functions as a performance improvement consultant to other safety and quality team members, YNHHS delivery networks, and service lines.
• 14. Through informal leadership, coordinates quality and safety team members in maintaining core functions of the quality and safety department. Encourages the development of innovative projects to improve quality, efficiency, safety, and reliability and assures evidence-based practice is utilized in all improvement activities.
• 15. Acts as a primary preceptor and mentor for new employees and provides education to enhance group knowledge of performance improvement and safety tools and methodologies.
• 16. Coordinates interdisciplinary teams, including senior leadership and frontline staff, aligning with system-wide care signature initiatives.
• 17. Performs other duties as assigned by the Safety and Quality leadership team

EDUCATION

Bachelors required. Masters Degree required OR a Bachelors degree and a minimum of 4 years of direct healthcare quality experience in lieu of a Masters Degree.

EXPERIENCE

With a Masters degree, three (3) to five (5) years of experience in project management in a healthcare setting with demonstrated success in the leadership of significant projects OR a minimum of two (2) years as a Quality and Safety Specialist II within the department. With a Bachelors degree, a minimum of 4 years experience of direct healthcare quality experience with demonstrated success in the leadership of significant projects.

Understand how systems of safety, safety culture, reliability, and continuous learning create safe patient care. Knowledge of patient safety and quality resources available through various channels and utilizes evidence -based research. Has an understanding of and assists with ensuring compliance with mandated state, federal, and regulatory agencies, rules, codes, laws, and standards that impact patient safety and quality. Familiarity with federal and state quality and safety programs that impact hospitals' public performance and reputation. Demonstrated history of leading successful improvement work including success with the development, monitoring, and sustainability of action plans. Proficiency with Excel and PowerPoint. Strong presentation and facilitation skills. Patient-oriented team player with the flexibility to adapt to evolving priorities.

LICENSURE

Valid RN license or related healthcare professional license preferred but not required.

Certified Professional in Healthcare Quality (CPHQ) by the National Association for Healthcare Quality OR Certified Professional in Patient Safety (CPPS) is required.

*Employees impacted due to the Quality & Safety restructure who otherwise meet the qualifications for this position will be considered with the requirement that the CPHQ or CPPS certification is achieved within 6 months of start date.*

SPECIAL SKILLS

Decision Making: Ability to make decisions guided by precedents, policies, and objectives. Problem Solving: Ability to address problems that are highly varied, complex, and often non-recurring, requiring staff input and innovative, creative, and Lean diagnostic techniques to resolve issues. Independence of Action: Ability to set goals and determine how to accomplish defined results with some guidelines. The Manager/Director provides broad guidance and overall direction. Written Communications: Ability to communicate clearly and effectively in written English with internal and external customers. Oral Communications: Ability to communicate effectively with medical center staff, patients, families, and external customers. Knowledge: Ability to demonstrate in-depth knowledge of concepts, practices, and policies and use them in complex, varied situations. Teamwork: Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Customer Service: Ability to provide an elevated level of customer service to patients, visitors, staff, and internal and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem-solving. Ability to remain calm in stressful situations.