Quality Improvement Specialist II

• Facilitate the accreditation and re-accreditation activities including communicating the process to relevant staff, preparing for inspections, and completing assessments and response plans. Assist in the assessment, measurement, and reporting of ongoing compliance with the Joint Commission accreditation standards and other regulatory requirements.

 • Work in collaboration with key members of the organization to identify education needs, develop corrective action plans in response to compliance issues, and participate as appropriate in the execution of improvement strategies and education activities that support a culture of continuous compliance with quality and safety regulations and practices.

• Assist in implementation of Continuous Improvement Initiatives, which depending on area of assignment may include, new QI system, Disease Management Program, Patient Safety Walkrounds Program, Clinical Indicators, Sentinel Events, Mortality & Morbidity rates and other.

• Submit recommendations on annual reviews/revisions within relevant QI programs/activities, databases, indicators, etc. Perform concurrent QI reviews of the assigned area, utilizing approved Indicators Monitoring System (IMS) databases, indicators or criteria. Conduct site visits to work with staff on relevant quality improvement/management programs/activities; submit detailed site visit reports with required observations.

• Responsible for reviewing results of committee meetings, mini focus studies, QI Team activities, etc. from relevant assigned facilities, and prepare quarterly reports. Coordinate QI activities with relevant department to maximize staff expertise in the area of Quality Improvement.

• Prepare monthly/quarterly reports on QI program and compliance. Assist in training junior staff and conducting QI Workshops. Attend Quality Improvement Committee meetings in the assigned clinical area.
• Perform other job related duties.

Responsibility level
Non-supervisory
Systems and Equipment

• Quality Improvement and data analysis tools and techniques
• Microsoft Office Suite
Relationships and Communications

• All involved internal disciplines
Decisions and Judgments

• Critical-thinking skills to reach objective conclusions
• Expected to work with minimum supervision, reporting to line manager when required
Mental Demands

• High paced environment with intense deadlines
Physical Demands

• Perpetual interaction with relevant stakeholders

Education:

Bachelor Degree in Health Administration/Sciences or Healthcare

Profession from an accredited institution – Essential ; or Bachelor Degree in non-Healthcare Profession with Master’s Degree in Quality and Health Management/Health Administration/Business Administration from an accredited institution – Essential
Certified Professional in Healthcare Quality [CPHQ] or other relevant Quality Improvement/Management Certification or equivalent – Preferred
Work Experience:
Minimum of 2 (two) years’ experience in related field in similar healthcare facility – Essential