Responsibilities:

• Manages performance improvement regarding SQPE with all departments providing patient care.
• Acts as an accountable partner for all clinical areas within their areas of responsibility.
• Understands and implements elements of performance as outlined by regulations, bylaws, and rules and regulations established by the medical staff. Acts as the primary resource for staff to facilitate overall operations of programs.
• Develop meaningful quality assurance activities with clinical leadership to establish when a deviation in standard practice has occurred.
• Analyzes performance data and participates in improvement strategy development.
• Acts as a consultant in educating and evaluating clinical and support department staff regarding quality management regulations and standards of care.
• Supports medical staff quality assurance activities such as peer review, ongoing professional practice evaluation, and focused professional practice evaluation.
• Develops and assures processes to monitor performance and identify where intervention is needed.
• Incorporates regulatory and accreditation standards into improvement activities around SQPE.
• Collaborates on development of required plans such as the performance improvement plan, safety plan, infection control plan, and others as required by governance.
• Incorporates enterprise priorities and regulatory requirements and benchmarks ensuring alignment to one standard of care across locations.
• Drives continuous improvement activity around quality, safety and patient experience priorities and coordinates improvement projects.
• Facilitates dashboard reviews, data analysis and decision-making from data. Identify and address root causes to lead to sustainable improvement.
• Acts as a champion for continuous improvement utilizing the Cleveland Clinic Improvement Model.
• Manages improvement projects to the desired key result.
• Manages stakeholder relationships, project risks and project changes.
• Leads projects leveraging advanced continuous improvement and project management tools.
• Research best practices within and outside the organization.
• Manages change to ensure the adoption and sustainment of quality improvement.
• Builds relationships with project teams, middle management, and senior sponsors.
• Coach smaller improvement teams to success with their quality improvement projects at the local level.
• Participates in committees and meetings necessary to drive performance in the assigned scope of the role.
• Reports on medical errors and near misses, as well as corrective actions taken. Oversees the management and use of medical error information.
• Applies the Cleveland Clinic cause analysis process to identify key factors that lead to failures in SQPE. Apply common cause analysis identification to safety events.
• Should have experience in the primary service line supported by the role if this role is supporting an enterprise service line.
• Other duties as assigned.

Language:

• English.

Education:

• Bachelor’s degree in nursing, Healthcare Administration, Business, Engineering, or related field required.
• Master’s degree preferred.

Certifications:

• Certified Patient Safety Professional (CPPS) or Certified Professional in Healthcare Quality (CPHQ) required within one year of hire.
• Registered Nurse Preferred

Other preferred certifications:  

• Certified Patient Safety Professional (CPPS)  
• Healthcare Accreditation Certification Program (HACP) or Certified Joint Commission Professional (CJCP)   
• Process Improvement Certification preferred: Lean, Six Sigma, etc.  
• Certified in Infection Control (CIC)  
• Certified Patient Experience Professional (CPXP)  

Complexity of Work:

• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
• Supports   a large specialty hospital, academic medical center, or an enterprise assignment.
• Must be able to work in a stressful environment and take appropriate action.
• Must represent clinical transformation in embodiment of Cleveland Clinic values.
• Ability to engage senior management and apply critical thinking and decisive judgment.
• Familiarity with basic statistical analysis, CI (Continuous Improvement) tools and change management techniques.
• Effective communication skills and ability to collaborate with all organizational levels.
• Must be able to work in a dynamic ever-changing environment and take appropriate action.

Work Experience:

• Minimum seven (7) years of related experience with safety, quality, patient experience and Performance Improvement program or related healthcare experience.
• Previous experience in working with Joint Commission, HFAP, CMS (Centers for Medicare and Medicaid: Government agency that provides reimbursement for accredited trainees) surveys process preferably in a leadership/coordination role.
• In-depth knowledge of patient safety best practices, joint commission standards, and conditions of participation.
• Clinical experience preferred and will offset three (3) years of experience requirement in SQPE.

Physical Requirements:

• Ability to communicate and exchange accurate information.
• Ability to perform work in a stationary position for extended periods.
• Ability to work with physical records or operate a computer or other office equipment.
• In some locations, ability to travel throughout the hospital system.
• In some locations the ability to move up to 25 lbs.

Personal Protective Equipment:

• Follow standard precautions using personal protective equipment as required.