Quality and Patient Safety Specialist

Greater Baltimore Medical Center, Inc.; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Greater Baltimore Medical Center, Inc. seeks a qualified quality and patient safety professional with 3+ years of experience in accredited healthcare settings. The role leads regulatory coordination, performance improvement, and data-driven safety initiatives across departments.

You will facilitate improvements, provide staff education, and prepare leadership reports to support governance. A nursing background and CPPS/CPHQ timelines are preferred for progression.

Qualifications

• Bachelor's degree in nursing required.
• Master's degree preferred.
• Minimum 3 years in Joint Commission accredited hospital or similar.
• Experience in accreditation/regulatory coordination and quality.
• Experience in quality improvement and patient safety.
• Knowledge of CMS/Leapfrog external measures.

Responsibilities

• Participates during onsite TJC and CMS survey site visits.
• Conducts orientation of new employees on quality and patient safety.
• R rounds on assigned units with leaders and staff.
• Reviews safety events and triages for corrective actions.
• Facilitates Comprehensive Systematic Analyses (RCAs/ACAs/FMEAs).
• Collaborates with clinical, operational, and data teams to monitor trends.
• Prepares clear quality performance summaries for committees and boards.
• Leads improvement activities using IHI Model, PDSA, and A3.

Skills

Interpersonal communication

Organization

Verbal communication

Problem solving

Team facilitation

Excel

PowerPoint

Outlook

Medical terminology

EMR navigation

Chart review

Investigation skills

Quality improvement

Patient safety

Regulatory compliance

Action planning

Data analysis

Report writing

RCAs

FMEAs

PDSA

IHI Model

Process improvement

Education delivery

Education

Bachelor's in Nursing

Master's preferred

Tools

EMR systems

Job description

Education:

• Bachelor's degree in nursing; Master's degree preferred

Experience:

• At least 3 years' experience in a Joint Commission accredited hospital or other similar healthcare environment.
• At least 3 years' experience in accreditation/regulatory/certification coordination and preparedness, performance improvement or patient safety preferred.
• Experience with quality improvement, patient safety, healthcare regulatory compliance, and action planning.

Licensures and Certifications:

• Licensed Registered Nurse
• Certification in Patient Safety (CPPS) within 1 year and/or Certification in Healthcare Quality (CPHQ) within 2 years

Skills:

• Excellent interpersonal communication skills necessary to interact effectively with a wide variety of constituents.
• Excellent organization, verbal and written communication, problem solving and team facilitation skills.
• Skill in using a computer and a variety of personal productivity applications (Excel, PowerPoint, Outlook, etc.)
• Ability to exercise judgment in interpreting and applying standards of care, regulations, hospital policies, procedures, and processes.
• Ability to review, analyze and develop clinical summaries of patient charts and identify the need for physician peer review.
• Knowledge of medical terminology and navigation of electronic medical record.
• Skill in conducting investigations, including chart reviews and timelines, in order to address patient safety and quality issues.
• Demonstrated working knowledge of eCQMs and externally reported quality measures, including CMS, Leapfrog, and other reputational and governing bodies, and supports accurate abstraction, validation, and submission processes
• Skill in providing consultation, coaching, and support to hospital staff
• Ability to deliver educational and training materials to clinical and support staff teams.
• Ability to facilitate improvement, specifically Comprehensive Systematic Analyses which may include RCAs, ACAs and FMEAs.
• Familiar with the Model for Improvement - PDSA.
• Knowledge of process improvement principles and ability to lead teams toward fixing reoccurring issues.
• Ability to gather, create reports, interpret and analyze data.

Principal Duties and Responsibilities:

• Participates and assists during onsite TJC and CMS survey site visits.
• Conducts orientation of new employees and nursing related to quality and patient safety. Provides on-going staff education and support.
• Regularly rounds on assigned units/departments ensuring a collaborative relationship with those areas' leaders and staff
• Reviews safety events from the incident reporting system as assigned and triages appropriately for potentially compensable events and reportable events. Ensures follow-up is appropriate and conducts follow-up as necessary. Prepares analysis of events and action items
• Facilitates Comprehensive Systematic Analyses as designated by the Risk Prioritization Matrix and submits reports as required to regulatory agencies. Ensures thorough analyses are conducted and include appropriate corrective actions and measures of success. Tracks completion of corrective action and escalates when needed
• Partners and collaborates with clinical, operational, and data teams to monitor trends, identify variation and improvement opportunities and drive sustainable improvement in outcome, process, and patient experience measures. Consults with leadership to follow up on action items required to improve processes identified through analysis and investigation.
• Leads analysis and improvement of key quality outcomes across acute care settings, translating performance data into targeted improvement strategies that align with organizational priorities and regulatory requirements
• Supports governance and leadership reporting, preparing clear, actionable quality performance summaries for committees, executives, and boards.
• Facilitates assigned committees, task forces, or improvement teams.
• Effectively leads through influence in a matrixed environment, facilitating collaboration with operational and clinical leaders to drive alignment, accountability, and measurable quality improvement
• Conducts improvement activities in collaboration with the Performance Improvement Team and independently using tools such as: IHI Model for Improvement, PDSA, A3.
• Makes appropriate decisions about the need for physician peer review and facilitates timely physician peer review. Responsibili