In this role you will be: Patient Safety • Support the organization's patient safety program and promote a culture of safety and continuous improvement. • Review patient safety events, incident reports, and near misses for trends, contributing factors, and opportunities for improvement. • Assist with event investigation, including information gathering, interviews, documentation review, and identification of contributing factors. • Support Root Cause Analyses (RCA), Action Plans, and other patient safety improvement methodologies as assigned. • Assist with implementation and monitoring of patient safety initiatives and corrective actions. • Support the organization's Good Catch/near-miss recognition and patient safety reporting programs. • Assist with patient safety huddles, safety rounding, and other proactive safety activities. • Escalate significant patient safety concerns to the appropriate leader promptly. Quality & Performance Improvement • Monitor and analyze quality and performance improvement data to identify trends, opportunities for improvement, and areas of risk. • Assist with the development, implementation, and monitoring of quality improvement initiatives and action plans. • Prepare quality reports, dashboards, presentations, and other materials for leadership and committee review. • Assist departments in establishing measurable goals and monitoring progress toward identified quality objectives. • Participate in performance improvement teams and interdisciplinary quality initiatives. • Assist with review and trending of hospital quality indicators, including clinical outcomes, process measures, patient experience measures, and other organizational performance metrics. • Identify trends and communicate significant findings to appropriate leadership. Regulatory & Accreditation • Assist with organizational readiness for regulatory and accreditation surveys, including CMS, Department of Health, accrediting bodies and other applicable organizations. • Monitor regulatory and accreditation requirements and communicate relevant changes to leadership. • Assist with regulatory gap analyses and development of corrective action plans. • Track findings, action plans, responsible parties, and completion dates. • Participate in tracer activities, environmental rounds, mock surveys, and other readiness activities. • Assist with preparation of documentation and evidence of compliance for regulatory and accreditation reviews. Data & Reporting • Collect, validate, analyze, and trend quality and patient safety data. • Maintain accurate quality and patient safety databases, trackers, and reporting systems. • Develop reports and presentations for quality committees, leadership, and other stakeholders. • Assist with identification of statistically or operationally significant trends. • Ensure data is reported accurately, timely, and in accordance with organizational and regulatory requirements. • Support benchmarking activities and comparison of organizational performance against applicable national, state, regulatory, and peer benchmarks. Committees & Leadership Support • Support the work of Quality, Patient Safety, Performance Improvement, and other related committees. • Prepare agendas, reports, data, and other materials as assigned. • Participate in committee meetings and document follow-up items when appropriate. • Track committee action items and ensure follow-up with responsible individuals. • Assist leadership with preparation of Board and executive-level quality and patient safety reports. Education & Staff Support • Serve as a resource to leaders and staff regarding quality improvement and patient safety processes. • Assist with development and delivery of education related to quality, patient safety, regulatory requirements, and performance improvement. • Promote consistent understanding and application of quality and patient safety practices. • Assist with Just Culture, patient safety, event reporting, RCA, and other quality-related education as assigned. OTHER DUTIES • Maintain confidentiality of patient, employee, medical staff, and organizational information. • Demonstrate professional judgment and appropriately escalate concerns involving patient safety, quality, regulatory compliance, or organizational risk. • Participate in organizational initiatives and special projects as assigned. • Maintain current knowledge of applicable healthcare regulations, accreditation standards, quality measures, and patient safety practices. • Perform other duties as assigned by the IRMC Director of Quality and MH Patient Safety Lead. Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. QUALIFICATIONS Required: • EDUCATION: • Bachelor's degree in healthcare administration, nursing, health information management, quality management, public health, or a related healthcare field preferred. • Equivalent combination of education and relevant healthcare quality/patient safety experience may be considered. • EXPERIENCE: • Experience in healthcare quality, patient safety, performance improvement, risk management, regulatory compliance, or a related healthcare field preferred. • Experience with data collection, analysis, trending, and reporting preferred. • Experience with regulatory/accreditation requirements preferred. • Experience with event investigation, RCA, or performance improvement methodologies preferred. • LICENSURE/CERTIFICATION: • Certified Professional in-Patient Safety or must obtain within two (2) years of eligibility.