Sr Quality Safety Specialist, Cartersville/Mountainside

Description:

JOB PURPOSE:
Specializes in bringing change to the organization through surveillance and analysis of clinical and
operational processes. Performs systematic review of complex processes related to Piedmonts Quality
Management Program including multidisciplinary professional practice evaluation, root cause analysis,
internal audit, policy management and infection prevention. Understands and interprets changes in
regulation, value based purchasing programs, accreditation and publically reported data. Drives quality
improvement through collection and timely dissemination of reliable information related to quality,
safety and service.

KEY RESPONSIBILITIES:
1. Performs surveillance activities for quality, safety, accreditation and infections for PHC inpatient and
outpatient services.
2. Supports Quality Management Programs including: Always Safe, RCA, PPE, error prevention,
performance reliability and Piedmonts Safety Coach Program.
3. Performs quality and safety training for new and existing staff
4. Provides expert support in data analytics (e.g. statistical process control, regression analysis,
correlational studies); report writing and development of stakeholder presentations.
5. Maintains knowledge of current and new reporting requirements for external
organizations/programs (e.g. CMS, AHRQ, DNV, State, Leapfrog, VBP, CDC, quality registries, etc.)
6. Supports multiple hospitals in understanding regulatory, reporting and accreditation changes and
their impact on hospital operations.
7. Maintains expert knowledge of existing and new quality measures, definitions, targets and
benchmarks
8. Abstracts clinical data from the Medical Record for various Quality databases using pre-existing
criteria.
9. Inputs data electronically for submission to Quality organizations and Core Measures within
established timeframes.
10. Collaborates with IT experts and process engineers to translate regulatory requirements into system
specifications
11. Maintains integrity and security of all information and data within the scope of the position with
strict confidentiality.
12. Conducts clinical chart review for quality measures as assigned.
13. Provides staff and physician interventions as appropriate, incorporating process improvement tools.
14. Provides guidance for the implementation of Evidence Based Medicine in quality initiatives and/or
throughout the pathway program.
15. Coordinates peer review process for medical staff, to include ongoing professional performance
evaluations and reappointment profile data.
16. Directs entry of essential infection control data into various electronic medical records and data
bases.
17. Participates in the Internal Audits conducted by the Surveillance and Analysis Team.
18. Assists with special projects.

MINIMUM EDUCATION REQUIRED:
Bachelors degree in nursing, statistics, business administration or other related field.
MINIMUM EXPERIENCE REQUIRED:
Five (5) years of work experience in healthcare, information management, or related field with at least
three (3) years of specific experience in a process improvement and/or quality role.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
None
ADDITIONAL PREFERRED QUALIFICATIONS:
Certification in Healthcare Quality (CPHQ) preferred
Current Georgia Nursing license or R.N. preferred
Masters Degree preferred