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Department: Medical Quality Management

Assists the Vice President Medical Affairs (VPMA) and Regional Director of Quality and Safety with the development and implementation of the Hospital-wide Performance Improvement and Risk Management Programs consistent with board approved plans and regulatory and standard setting agencies.
  • Reports to the Vice President of Medical Affairs


Minimum Education: Bachelor of Science in Health Care related field, Masters or JD preferred.

Minimum Experience:
  • Three to five years experience within a healthcare setting with a focus on patient safety, risk management or quality improvement.
  • Experience and/or demonstrated understanding of root cause analysis and FMEA analysis.
  • Experience in statistical analysis tools.

Minimum Skills/Abilities:

  1. Strong organizational skills.
  2. Strong interpersonal skills, ability to work across disciplines.
  3. Ability to analyze data, formulate meaningful information.
  4. Ability to work with, develop, motivate multi-disciplinary CQI Teams.
  5. Strong orientation to patient care in accordance with the Medical Center's values, particularly the holistic approach to healing.
  6. Ability to work with highly sensitive and confidential information with appropriate discretion.
  7. Able to communicate verbally and in writing in the English language.
  8. Strong computer and database skills

Certification/Licensure: ASHRM or CPHQ designation preferred
Training: Training in patient safety or risk management and quality/performance Improvement methodology, concepts, education and implementation.

Special Qualifications:
  • Membership and active participation in professional organization(s).
  1. Provides superior customer service to internal and external clients, customers, and patients as referenced in the Service Excellence Standards.
  2. Provides administrative support for the Quality and Safety Committee, Patient Safety Triage Team, Performance Improvement Task Forces and other related committees
  3. Attends departmental/hospital meetings where measurement and evaluation functions and quality management activities are performed, as agreed upon by the VPMA,Chairman of the committee or the Director of Service.
  4. Attends Performance Improvement Task Force meetings and Collaborative Group Practice meetings where performance improvement activities are conducted.
  5. Assists with the annual evaluation of the Performance Improvement Plan and Program, on behalf of the Performance Improvement Council. Assists with follow-up of patient safety and risk issues addressed by the Quality and Safety Committee.
  6. Assists departments with the development, implementation of hospital tracking system for quality and risk management issues. Orients personnel to required use.
  7. Assists departments with the integration of quality and risk management activities.
  8. Reviews departmental quality indicators for compliance, appropriateness and rationale.
  9. Reviews and analyzes incident reports, rates by severity and conducts all follow-up as identified from review.
  10. Completes trending analysis to identify top priority areas for improvement.
  11. Conducts root cause analysis in the event of a sentinel or near miss event.
  12. Coordinates review of medical information, debriefs all individuals as identified, performs cause and effect analysis and coordinates expert panel review, root solution and follow-up for all incidents identified.
  13. Conducts FMEA analysis when high volume, high risk opportunities are discovered through incident report analysis.
  14. Organizes team, creates process maps, creates failure modes analysis, and identifies prevention and/or corrective action strategies and implants as identified.
  15. Assists the VPMA with appropriate reporting of risk events to regulatory agencies and insurance carrier.
  16. Understanding and implementation of programs related to national and local patient safety initiatives.
  17. Acts as liaison to statewide and national collaborative for quality and safety initiatives.
  18. Available on beeper at all times during scheduled working hours.
  19. Performs all other job related duties as requested by the Director of Quality and Safety.

About AP Healthcare:

American Personnel Healthcare Division

The American Personnel Healthcare division provides staffing solutions for healthcare facilities. We manage supplemental staffing programs for hospitals, clinics and medical centers.

We offer a variety of Nursing and Healthcare assignments that give you more options to accommodate your life. For a sample of the available positions that fit your criteria apply today.

Hospitals and clinics require more than medical professionals to provide quality healthcare. The following are some of the areas we specialize in:

Nursing - Executive Leadership
Nursing Specialties
Medical Technologists
Healthcare Information Technology

Posted date: 4 years ago

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