Leads and oversees a comprehensive, efficient, and integrated hospital-wide Continuous Quality and Performance Improvement (CQPI) program. Uses data collection, analysis, and trending to assess performance; focuses on process and systems improvement; directs risk management and patient safety activities; investigates adverse outcomes; coordinates regulatory/accreditation readiness; and educates staff on CQPI and related quality programs.
Essential Functions- Provide leadership and oversight of the organization-wide CQPI program.
- Measure and assess performance by collecting, analyzing, and trending data to identify opportunities for improvement.
- Focus on improving processes and systems to drive clinical quality, safety, and operational performance.
- Direct, facilitate, and report on all aspects of risk management and patient safety.
- Investigate factors contributing to adverse outcomes and drive process/system changes.
- Direct the hospital-wide CQPI operations, including record reviews for quality indicators and reporting findings to leadership, Medical Executive Committee, Board of Managers, and other committees.
- Annually review hospital-wide plans for Infection Control (IC) and CQPI; establish goals and objectives for the coming year.
- Serve as liaison to local health officials; coordinate inspections and accreditation reviews with state and other regulatory agencies.
- Perform other duties as assigned.
Develops and delivers hospital-wide CQPI education and training. Prepares quality/patient safety reports and dashboards for leaders and committees. Partners with clinical and non-clinical departments to sustain improvements and ensure compliance with applicable standards.
Knowledge, Skills & AbilitiesLicensure: Registered Nurse with current state licensure highly preferred; clinical license required.
Education: BSN or BS/BA required.
Experience: Minimum two (2) years in an acute hospital or rehabilitation setting required; prior supervisory experience preferred.
Certifications: Basic Life Support (BLS/CPR) required; certification preferred by APIC (American Practitioners of Infection Control) and NAHCQ (National Association of Health Care Quality).
Skills: Data analysis and reporting; CQPI methodologies (e.g., RCA, FMEA, PDSA); risk management and patient safety facilitation; regulatory/accreditation readiness; effective teaching, communication, and collaboration.
Skills Required
- Clinical license required (e.g., state clinical license)
- Registered Nurse licensure (RN)
- BSN or BS/BA
- Minimum two (2) years in an acute hospital or rehabilitation setting
- Prior supervisory/management experience
- Basic Life Support (BLS/CPR) certification
- APIC and NAHCQ certification
- Data analysis and reporting skills
- CQPI methodologies (RCA, FMEA, PDSA)
- Risk management and patient safety facilitation
- Regulatory/accreditation readiness experience
- Effective teaching, communication, and collaboration skills
