Disease-Specific Quality & Safety Lead

Cape Fear Valley Health; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Cape Fear Valley Health is seeking a Quality & Patient Safety professional to lead performance improvement initiatives, coordinate data analysis and ensure evidence-based care across the organization. The role supports Joint Commission, CMS readiness and staff education to drive safe, effective patient care.

You will work with multidisciplinary teams to analyze data, develop improvement plans, and educate frontline staff on QA standards and regulatory compliance.

Qualifications

• Bachelor of Science in Nursing is required.
• Current RN licensure in North Carolina or a Compact state.
• Nurse Practitioner (NP) preferred.
• Minimum 2 years' experience in quality/patient safety and regulatory, quality processes and/or data analysis.
• Proficiency in reading, writing, and speaking English; strong data analysis and teamwork.

Responsibilities

• Educate on patient floors to drive quality of care and CMS/Leapfrog metrics.
• Coordinate ongoing education related to process, data analysis and tools with teams.
• Provide monthly reports to Quality Council/Patient Safety Team, MEC and Board on PI, Patient Safety and Regulatory.
• Coordinate hospital-wide PI/PS/Regulatory meetings as assigned.
• Identify and mitigate patient safety risks and coach staff and physicians in safe practices.
• Use project management tools to interpret data.
• Apply lean tools to reduce waste in cost, inventory, labor and distance.
• Coordinate Root Cause Analyses and Failure Mode and Effect Analyses as assigned.
• Demonstrate knowledge of Joint Commission and CMS standards.
• Assist with tri-annual Joint Commission survey and CMS/DHSR surveys.
• Stay current with CMS and regulatory standards for Core Measures.
• Assist multidisciplinary teams in transitions of care from acute to outpatient care.
• Support Joint Commission DSC process and performance measure compliance.
• Evaluate care processes for consistency with standards.

Skills

PI methodologies

Quality data analysis

Audit processes

Team collaboration

Statistical concepts

Documentation skills

Design of experiments

Regulatory knowledge (Joint Commission

Education

Bachelor of Science in Nursing

RN licensure (NC or compact state)

Job description

Cape Fear Valley Health is seeking a Quality & Patient Safety professional to lead performance improvement initiatives, coordinate data analysis and ensure evidence-based care across the organization. The role supports Joint Commission, CMS readiness and staff education to drive safe, effective patient care.

You will work with multidisciplinary teams to analyze data, develop improvement plans, and educate frontline staff on QA standards and regulatory compliance.