Primary City/State:

Phoenix, Arizona

Department Name:

Work Shift:

Day

Job Category:

Risk, Quality and Safety

POSITION SUMMARY
This position supports high reliability in clinical performance through ongoing assessment of performance, prioritizes clinical improvement activities, facilitates performance improvement, and promotes successful implementation to achieve entity/system targets. This role requires strong communication, collaboration, teamwork, and change management skills in order to achieve desired results across the continuum of care.

CORE FUNCTIONS
1. Quality Leadership and Integration - Facilitates the integration of quality into the fabric of the organization to achieve objectives, such as Annual Initiatives, Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (tJC) standards of care. Support the quality infrastructure, protect the use of privileged or confidential information, facilitate processes for engagement and interprofessional teamwork, identify and promote continuous learning opportunities to advance the organization/facility/entity and communicate effectively. Facilitates performance improvement projects with physicians, clinical leaders, and staff to identify improvement opportunities utilizing qualitative and quantitative data analysis, knowledge of health care operations and systems thinking.

2. Performance and Process Improvement – Serves as a subject matter expert in performance and process improvement, project management and change management methods to support operational and clinical quality initiatives. Facilitates activities related to or resulting from patient safety, harm reduction, clinical performance, peer review and compliance with regulatory and accrediting agencies. This is accomplished by utilizing performance and process improvement tools and principles, applying project management methods, and using change management principles and tools.

3. Population Health and Care Transitions - Evaluate and improve healthcare processes and care transitions to advance the efficient, effective, and safe care of defined populations. Foster integrated team-based clinical delivery model to population-based care.  Implement Clinical Practices, standardized process, that are evidence-based Population Health management strategies, encourage and contribute to a holistic approach to improvement and collaborate to improve care processes and transitions back to the community. Monitor and report facility Clinical Practice performance that have been handed-off to Quality Improvement.

4. Health Data Analytics - Supports the organizations' analytic environment to help guide data driven decision making while facilitating meetings with departments and teams to guide quality improvement initiatives and activities. Adheres to procedures for the confidentiality and integrity of data, designing, influencing, and monitoring data collection plans for Key Performance Indicators. Collaborates with process owner(s), acquiring, and integrating data from internal and external benchmarking sources. Uses statistical and visualization methods to analyze data for administrative and clinical decision making.  Provides on-going assessment of performance, analyzes clinical outcome data, and identifies performance improvement opportunities or trends. Conducts and reports to stakeholders in-depth assessment of qualitative and quantitative data.

5. Patient Safety - Participates in and contributes to a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Seves as an advocate for the patient safety culture, applying safety science principles/methods, identify and report patient safety risks/events and collaborates to analyze patient safety risks and events. They facilitate teams to improve processes that impact the safety of patients.

6. Regulatory and Accreditation - Supports the evaluating, monitoring, and improving compliance with internal and external requirements. Participates in processes to prepare for, participate in, and follow up on Regulatory Agencies and certifications. Participates in processes to support compliance with PI standards, contributes toward continuous survey readiness activities and participates in the survey processes and findings.

7. Quality Review and Accountability – Facilitate and support compliance with voluntary, mandatory, and contractual reporting requirement for data acquisition, analysis, reporting and process improvement. May support practitioner and nursing performance review activities as directed.

8. Professional Engagement - Engages in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competencies and advancing the field by integrating ethical standards into practice, engaging in lifelong learning and participating in activities that advance the profession, such as participation in professional organizations and achievement of certification in healthcare quality.

9. Responsibilities cross all levels of internal customers including the department, facility and system, and external customers including but not limited to the medical staff, the community, regulatory bodies and state agencies.

MINIMUM QUALIFICATIONS

Requires a Bachelor’s degree in nursing or other healthcare field (i.e.: Pharmacy, Physical Therapy, Respiratory Therapy, etc.).

If in a profession that requires licensure, current licensure/certification/registration is required for state worked.

Requires a proficiency level typically attained with five years acute care clinical experience.

Requires ability to perform complex statistical analysis and highly developed problem-solving skills. Requires the ability to manage programs and projects. Requires demonstrated excellence in interpersonal and written communication skills.

PREFERRED QUALIFICATIONS

Registered Nurse (RN) license preferred. Certified Professional in Healthcare Quality (CPHQ) certification is preferred.
Master’s Degree is preferred. Experience with process improvement, regulatory/accreditation programs, data management, and analysis including graphic development and presentations is highly desirable.

Additional related education and/or experience preferred.

EEO Statement:

EEO/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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