Because we all have a role
in making care exceptional

Responsibilities:

• Manages performance improvement regarding SQPE across a hospital location or assigned business units.

• Acts as an accountable partner and support for all clinical areas within their areas of responsibility

• Understands and implements elements of performance as outlined by regulations, bylaws, and rules and regulations established by the medical staff. Acts as the primary resource for staff to facilitate overall operations of programs.

• Develop meaningful quality assurance and improvement activities with clinical and operations leadership to establish when a deviation in standard practice has occurred.

• Analyzes performance data and participates in improvement strategy development.

• Acts as a consultant in educating and evaluating clinical and support department staff regarding quality management regulations and standards of care.

• Supports medical staff quality assurance activities such as peer review, ongoing professional practice evaluation, and focused professional practice evaluation.

• Develops and assures processes to monitor performance, identifies where intervention is needed and leads change to drive and sustain improvement.

• Incorporates regulatory and accreditation standards into improvement activities around SQPE.

• Supports implementation of required plans such as the performance improvement plan, safety plan, infection control plan, and others as required by governance.

• Incorporates enterprise priorities and regulatory requirements and benchmarks ensuring alignment to one standard of care.

• Drives continuous improvement activity around quality, safety and patient experience priorities and coordinates improvement projects.

• Facilitates dashboard reviews, data analysis and decision-making from data.

• Supports identification of root causes and action planning to lead to sustainable improvement.

• Coordinates improvement projects to the desired key result.

• Implements and reinforces best practices within and outside the organization.

• Monitors and facilitates the adoption and sustainment of quality improvement.

• Builds relationships with project teams, medical staff and other clinical and non-clinical stakeholders, and sponsors.

• Coach improvement teams to success with their quality improvement projects at the local level.

• Participates in committees and meetings necessary to drive performance in the assigned scope of the role.

• Reports on medical errors and near misses, as well as corrective actions taken.

• Analyzes and reports safety event data for trends to reinforce error prevention and high reliability.

• Applies the Cleveland Clinic cause analysis process to identify key factors that lead to failures in SQPE. Apply common cause analysis identification to safety events.

• Other duties as assigned.

Education:

• Required: Bachelor’s degree in nursing, Healthcare Administration, Business, Engineering, or related field.   In lieu of Bachelor’s degree, five (5) years of Safety, Quality, Patient Experience, Accreditation, Risk, Clinical, or Continuous Improvement experience may suffice.

• Preferred: Master’s degree.

Languages:

• English

Certifications:

• Preferred Certified Patient Safety Professional (CPPS)

• Preferred Certified Professional in Healthcare Quality (CPHQ) preferred and can be accepted in lieu of CPPS.

• Registered Nurse Preferred.

Other preferred certifications:

• Healthcare Accreditation Certification Program (HACP) or Certified Joint Commission Professional (CJCP) 

• Process Improvement Certification preferred: Lean, Six Sigma, etc.

• Certified in Infection Control (CIC)

• Certified Patient Experience Professional (CPXP)

Complexity of Work:

• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.

• Works to support a community hospital or large specialty hospital.

• Must be able to work in a stressful environment and take appropriate action.

• Must represent clinical transformation in embodiment of Cleveland Clinic values.

• Ability to influence, collaborate, and engage diverse range of healthcare professionals and senior leaders and apply critical thinking and decisive judgment.

• Familiarity with basic statistical analysis, CI (Continuous Improvement) tools and change management techniques.

• Effective communication skills and ability to collaborate at all organizational levels.

• Must be able to work in a dynamic ever-changing environment and take appropriate action.

Work Experience:

• Minimum one (1) year of related experience with Safety, Quality, Patient Experience, Accreditation, Risk, Clinical, or Continuous Improvement.

• Preferred experience in working with Joint Commission, HFAP, CMS (Centers for Medicare and Medicaid: Government agency that provides reimbursement for accredited trainees) surveys process preferably in a leadership/coordination role.

• Understanding of patient safety best practices, joint commission standards, and conditions of participation.

• Clinical experience preferred.

Physical Requirements:

• Ability to communicate and exchange accurate information.

• Ability to perform work in a stationary position for extended periods.

• Ability to work with physical records or operate a computer or other office equipment.

• In some locations, ability to travel throughout the hospital system.

• In some locations the ability to move up to 25 lbs.

Personal Protective Equipment:

• Follow standard precautions using personal protective equipment as required.