• Acute Care Quality & Patient Safety Specialist - Bethesda and Southdale

    Job Location US-MN-St. Paul
    Job ID
    Quality/Performance Improvement
    Contract Status
    Authorized Hours
  • Overview

    The Quality and Pt. Safety Specialist is responsible for the collaborative development, implementation, and management of a quality and patient safety assessment and performance improvement program for regional acute care services. Experience in Quality/Pt. Safety concepts, Performance Improvement, and regulatory requirements are foundational. Experience in leading multidisciplinary teams (including physicians, leaders, and staff), and assisting in accreditation/ regulatory readiness and surveys. Extensive experience in Quality, Performance Improvement, data interpretation, software knowledge and management for event reporting, and regulatory requirements.The Quality and Patient Safety Specialist investigates/explores complex organizational issues in order to identify and develop priorities for improvement. This role is responsible for developing process/performance improvement plans, directing/managing implementation teams, assure long-term success, and bringing projects to completion. Serve as an expert who possesses the knowledge and skill required to facilitate breakthrough improvement in key processes that support overall objectives of quality and pt. safety across the organization, and at the entity/region of support. Work with front line staff on improvement efforts.


    • Partners with system leaders to coordinate the Quality and Safety Program and develops, implements and maintains an effective, ongoing hospital-wide, data driven quality assessment and quality improvement program. Assesses quality for the defined patient population and determine priorities for performance improvement
    • Provides basic support for the Clinical Councils in partnership with the physician and nursing leadership. Develops and maintains a current quality plan, develops and provides ongoing support for scorecards and data needs, reviews quality measurement data on a regular basis; identifies, prioritize and monitors improvement activities
    • Collaborates with leadership to analyze data from the electronic safety reporting system and develops priorities for improvement. Reviews events and assures accuracy with consistently applied definitions, assures events are reviewed by all involved leaders and closes event when complete
    • Partners with leaders and system experts around patient safety efforts. Oversees the Root Cause Analysis process (RCA), facilitates and documents event details, works with team to create robust action plans, implements changes. Completes all required processes for reporting and documentation for all reportable adverse health events
    • Completes mortality reviews. Identifies and reports those which require notification to regulatory agencies, reviews for quality issues and opportunities to improve Failure to Rescue and refers to appropriate leaders.
    • Serves as the chapter expert for selected Joint Commission chapters and CMS conditions of participation, including Performance Improvement and the National Patient Safety Goals. Serves as a consultant during surveys involving the Joint Commission, CMS, MDH and other regulatory agencies. Oversees the selection and completion of required FMEA activities
    • Partners with leaders and the data/informatics team to design effective measurement plan. Develops and provides and ongoing support for scorecards and data needs, reviews quality measurement data on a regular basis and to identify, prioritize and monitor improvement activities
    • Prepares analysis of clinical data, including the identification and abstraction of appropriate data. May serve as the subject matter expert for the functionality of the electronic event software suite
    • Facilitate quality/patient safety performance improvement teams; manage projects. Facilitate improvement teams’ methodology to successful project completion. Ensure that appropriate improvement methodology is applied to each project. Utilize team facilitation skills and process improvement tools effectively. Inspire and guide team to goal achievement. Provide support and ongoing learning. Facilitate meetings to achieve results
    • Maintains knowledge of, and complies with, all relevant laws, regulations, policies, procedures and standards
    • Actively participates in creating and implementing improvements
    • Performs other responsibilities as needed/assigned



    • Bachelor's degree in Business, Nursing, Healthcare or related field required
    • MBA, MHA, or Masters Degree in related field preferred
    • Certified Professional in Healthcare Quality (CPHQ) through Healthcare Quality Certification Board preferred

    • 10+ years nursing or healthcare experience with some quality/patient safety, and process improvement and/or project management experience or three years leading performance improvement efforts utilizing formal tools and methodology required

    • 3 years management experience preferred

    • Knowledge of quality, patient safety and improvement principles, tools and methods

    • Knowledge of regulatory requirements, including Joint Commission and CMS preferred

    • Computer skills in Microsoft Word, Excel, Visio, and PowerPoint

    • Data management and assessment skills

    • Clinical knowledge base with review and assessment of clinical records and data

    • Evidence-Based Practice knowledge and skills

    • Change Management: Skilled in consulting with individuals and groups navigating through significant changes

    • Influencing: Uses appropriate interpersonal skills and techniques to gain acceptance for ideas or solutions. Uses influencing strategies to gain genuine agreements; seeks to persuade rather than force solutions or impose decisions or regulations

    • Interpersonal Communication: Skilled in developing effective rapport with customers, co-workers, or families, actively listening to develop a positive connection

    • Interpersonal Savvy: Relates well to all kinds of people, builds rapport easily, builds constructive and effective relationships, uses diplomacy and tact, can defuse even a high-tension situation comfortably

    • Organization: Effective management of projects, deadlines, and work load prioritizing; putting things together in an orderly and functional whole

    • Project Management: Knowledge of the principles, methods, or tools for developing, scheduling, coordinating, and managing projects and resources, including monitoring and inspecting costs, work, and contractor performance

    • Time Management: Uses his/her time efficiently, accurately scopes out length and difficulty of tasks and projects, breaks down work into processes, develops schedules and tasks, anticipates and adjusts for problems. Strong attention to detail



    About HealthEast


    At HealthEast, our patients are our neighbors and we are dedicated to their, and our, optimal health and well-being. We are guided by our faith-based heritage, a call to healing that respects the dignity and culture of every person. We empower our patients with user-friendly access to their health information, dependable service, and affordable, high-quality care.


    We put new, more efficient models of care into practice, allowing our 7,500 employees and 850 physicians to focus on what’s important: providing compassionate health care that puts the patient and their needs first. With 14 clinics, home care, a medical transportation center, and four hospitals — Bethesda Hospital, St. John’s Hospital, St. Joseph’s Hospital, and Woodwinds Health Campus — we provide excellent family health and specialization, including primary, maternity, orthopaedics and post-acute care.


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