Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible. Under the supervision of the Director of Infection Control and Staff Development, the specialist provides diversified support for the organization's performance improvement, regulatory, accreditation, patient safety, and health plan quality activities. Responsible for performance improvement related case reviews, focus studies, and other initiatives. Leads and/or facilitates multidisciplinary teams in identifying, prioritizing, and implementing performance improvement projects. Additionally, Responsible for reporting unbiased data, findings and summaries to the QAPI Committee on at least a quarterly basis and more often as needed. Participates in healthcare failure modes, effects analysis, and root cause analysis activities, as required. Acts as an internal consultant and effectively collaborates with medical staff and departments regarding regulatory, accreditation and continual readiness efforts. Collects and processes quality data so that staff may identify areas for improvement. Monitors clinical performance to ensure patient safety and promote quality outcomes. Prepares and analyzes data to report to performance improvement, accreditation, and safety-related committees. Assists with all components of regulatory and other quality programs, accreditation preparedness and continual readiness. Demonstrates an understanding, and maintains current knowledge of regulatory quality program specifications, the accreditation process and/or survey process, including standards, process revisions, and team dynamics and interoperability. Assists with Virtual Survey and/or CMS Validation activity preparation, completion, and follow-up for opportunities identified. Completes organizational mock survey and tracer activity as required. Assists departments throughout the organization with quality program activities, accreditation-related activities, as necessary. Leads or facilitates performance improvement teams/processes related to quality programs, accreditation/survey issues, including Core Measures, as assigned. Conducts audits and focus studies to evaluate compliance with selected elements as required. Leads and serves as a liaison in clinical quality measures and core measure data collection and analysis and other duties as required and directed. Functions as a key facilitator of performance improvement throughout the organization. Functions as PI internal consultant and subject matter expert, and assists departments with PI education, initiatives and opportunities as directed. Completes organizational focus studies, case reviews, and audits where required, including analysis of results, and identification of suggested improvement strategies. Participates at level assigned by supervisor or manager in organizational performance improvement initiatives Maintains open communication within the department, keeping key department members aware of quality and safety issues, as evidenced by feedback and direct observation Effectively participates in activities designed to improve patient safety. Department liaison for initiatives such as compliance with restraint management, compliance with National Patient Safety Goals, AHRQ Patient Safety Indicators (PSI), and so on. Effectively participates in activities designed to improve quality of care through active participation in initiatives designed to improve process of care and outcomes, reduce medical errors, patient falls, medication errors, and so on. Reports barriers to success in a timely manner. Active member of quality related committees, as assigned. Demonstrates ongoing competence and upgrades knowledge through continued education. Attends educational programs offered through such organizations as

HANYS, CMS, NYS

DOH, Leading Age NY and so on, to attain current information. Reviews and forwards pertinent reading material addressing PI, quality, accreditation, or patient safety issues to applicable departments. Supports organizational strategies and initiatives related to quality improvement, accreditation and patient safety as a result of knowledge obtained through continuing education, as evidenced by review of suggestions received Performs similar or related duties as requested or directed. Additional functions for Nursing Home based

Quality Specialist:

Provides education on quality, accreditation/survey process and continual readiness topics Completes other quality program and survey-related assignments as directed (e.g. Quality measure review, 5- Star, Nursing Home compare data, etc.) Leads or participates in patient safety activities, and/or survey review

Education:

2 Year / Associate Degree in nursing or healthcare related field, required. Experience may be considered in lieu of education 4 Year / Bachelor's Degree, preferred

Experience:

Minimum 1 year of experience in healthcare or a healthcare related field, required Experience with Joint Commission standards and survey process, CMS, NYS DOH regulations, and audit process, preferred

Licensure/Certifications:

NYS RN Licensure, preferred

Skills:

Computer Skills Communication Organizing/Categorizing records

Technical Skills Clinical Skills Auditing Time Management Physical Requirements:

Light Work - Exerting up to 20 lbs of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg control requires exertion of forces greater than that of sedentary work and if the worker sits most of the time, the job is considered light work Occasional balancing, lifting, pulling, pushing, reaching, and standing Frequent grasping and walking Constant typing/clerical/dexterity, hearing, repetitive motion, seeing/monitor/computer use, talking, and visual acuity (color, depth, perception)

Hazards:

Occasional bodily fluids/bloodborne exposure

Travel:

Occasional Travel - The job may require travel from time- to-time, but not on a regular basis.