This position is responsible for the coordination of performance improvement, continuous regulatory readiness and patient safety activities for Nemours Children's Health, Florida which includes the Hospital, satellite locations, affiliate operations and other locations as assigned. Responsibilities include oversight and direct participation in the collecting, organizing, compiling, documenting, and analyzing data from a variety of sources to produce reports from which opportunities for quality/safety improvement, intervention and educational activities can be identified. This individual will coordinate and participate in the collection of data from medical records, logs, databases and error reporting systems that support performance improvement, patient safety, and regulatory readiness activities of the Hospital and the Practice. Educates staff in performance/quality improvement and patient safety concepts, processes, and tools as needed within the scope of these responsibilities. Utilizes the quality methodology in training departments and multi-disciplinary teams. Works with Hospital and Medical staff at all levels of the organization to design and implement data collection methodologies, databases, action plans, and reporting strategies. Facilitates teams as necessary to achieve performance improvement and continuous regulatory readiness within the organization. Coordinates and conducts evaluation of hospital and medical staff processes via Tracer Methodology to support compliance with state, federal and other regulatory agencies' standards.

Position Responsibilities

• Assists in the identification of specific organizational needs and priorities related to quality improvement and patient safety utilizing a variety of sources including, but not limited to, measurement data, variance reports, patient/family suggestions, team recommendations, comparative data, regulatory standards/reports, focus groups and knowledge-based information.
• Supports on-site survey activities with regulatory agencies.
• Establishes a process, in collaboration with Departmental Leaders, for proactively assessing the organization for quality and safety improvement opportunities.
• Educates and acts as a resource to all hospital and practice personnel on quality methodologies and regulatory standards related to quality and patient safety
• Designs data collection processes and tools as appropriate to the project.
• Conducts concurrent and retrospective focused studies to evaluate and analyze targeted areas of performance.
• Analyzes data to identify trends and opportunities for improvement as assigned. Prepares data into meaningful information using forms, reports, graphs, tables, slides, and other documents to communicate results.
• Presents as appropriate data results to administration, medical staff, departments, and committees.
• Utilizes Tracer Methodology to assess compliance with Accreditation and Regulatory requirements.
• Facilitates and/or prepares formal documents, reports, plans or policies to support quality and safety activities, i.e. Root Cause Analysis, Failure Mode Effects Analysis, Team Proposal forms, progress reports, data definitions, etc.
• Responsible for process improvement work related to root cause analysis (RCA), ongoing monitoring, and supporting the execution of systemic changes to prevent recurrence in alignment with the PDSA cycle.
• Additional miscellaneous duties and responsibilities, as may be assigned from time to time by employee's supervisor.

Position Requirements

• Bachelors Degree required
• CPHQ and other quality certifications preferred
• More than 5 years experience in health care performance/quality improvement, patient safety, and regulatory