Quality Improvement Specialist

State-of-Missour; St. Louis (MO); On-site; USD 65,000 - 90,000; Full time

Job summary

Eastern Missouri Psychiatric Hospital System is seeking a Quality Improvement Specialist to strengthen fire safety, emergency preparedness, and regulatory compliance across three campuses. The role focuses on planning, coordinating, and evaluating fire drills and disaster simulations, and updating EPP/COOP plans in line with TJC, CMS, NFPA standards.

The candidate will lead HVA analyses, training, and cross‑campus safety initiatives, while collaborating with Maintenance and Security.

Qualifications

• No discipline within the last 12 months (internal candidates).
• Bachelor's degree in safety, public health, environmental health, occupational safety, healthcare field or other related field required.
• Two (2) years' experience related to workplace safety, environmental science, regulatory compliance, healthcare life safety, or healthcare environment of care.
• Master's degree in safety, public health, environmental health, occupational safety, healthcare field or other related field preferred.
• Four (4) years' experience with healthcare workplace safety, environmental science, TJC or CMS regulatory compliance, healthcare life safety, fire drills in healthcare, environmental disease response in healthcare or healthcare environment of care.
• Completion of FEMA courses 100, 200, 300

Responsibilities

• Plan, facilitate, monitor, evaluate and document fire drills for three campuses, ensuring regulatory requirements are met.
• Evaluate staff and consumer responses during drills to develop corrective action plans.
• Plan and document disaster drills (earthquake, tornado, active shooter) across campuses and debrief after actions.
• Facilitate HVA analysis, building tours, and update HVA reports across campuses.
• Lead EOC committee or Emergency Preparedness plan, and drive Performance Improvement projects.
• Update annual Emergency Preparedness Plans (EPP) and Continuity of Operations Plans (COOP).
• Collaborate with Maintenance and Security on Interim Life Safety Measures and fire watches as needed.
• Provide training to new and current staff on fire safety, emergency plans, HICS, and safety communications.
• Attend meetings, report to leadership, and participate in safety/compliance reviews and regulatory gap analyses.

Skills

Regulatory compliance

Emergency preparedness

Fire safety

Environmental health

Education

Bachelor's degree in safety, public health, environmental health, occupational safety, healthcare field or other related field

Master's degree in safety, public health, environmental health, occupational safety, healthcare field or other related field

Job description

Quality Improvement Specialist

Eastern Missouri Psychiatric Hospital System

Hawthorn and the Forensic Treatment Centers provide specialized care for clients diagnosed with mentalillness.WearelookingforaFireSafetyAssistanttoensurethatour facility, including clients and staff, remain safe.

Responsibilities (not exclusive)

Plan, facilitate, monitor, evaluate and document fire drills for the three campuses HCPH (Hawthorn Children's Psychiatric Hospital), FTC-N (St. Louis Forensic Treatment Center- North campus), and FTC-S (St. Louis Forensic Treatment Center- South Campus). All drills must meet regulatory requirements of the Joint Commission (TJC), and Centers for Medicare and Medicaid Services.Evaluate and assess the response of staff and consumers during the fire drill to develop individualized corrective action plans to improvement response performance for the three campuses. Plan, facilitate, monitor, evaluate and document disaster drills such as earthquake, tornado, active shooter, and any other drills for three the campuses. All drills must meet regulatory body requirements. Evaluate and assess the response of staff and consumers during the disaster drill to develop individualized corrective action plans to improve response performance for the three campuses. To plan, facilitate, monitor, evaluate and document debriefings or after action review of any disaster or drills. All documentation must meet regulatory body requirements. Facilitate the Hazardous Vulnerability Analysis (HVA) for the three campuses. This includes planning the building tours, analyzing the findings and assisting in updating the HVA report. Expert in Joint Commission Life Safety, Emergency Management and Environment of Care chapters, CMS A tag Physical Environment, E tag Emergency preparedness, K tag Life safety, core chapters and occupancy chapters of National Fire Protection Association (NFPA) 2012 edition for healthcare to utilize this knowledge during environmental safety inspections, tracers, mock surveys and rounds at for the three campuses. Chair and facilitate the Environment of care (EOC) committee or the Emergency Preparedness plan (EPP) committee for HCPH or FTC. Facilitates EOC Performance Improvement projects for the three campuses.

Completes analysis of the Fire and Safety Management plan and updates as needed once a year.

Provides training to new employees in New Employee Orientation (NEO) and current employees on an ongoing basis on fire safety, material safety data sheets, emergency preparedness plans, emergency codes and Hospital Incident Command System (HICS) for the three campuses.

Update, write, review and update annual emergency preparedness plans (EPP) for the three campuses to align with regulatory requirements of TJC and CMS. This includes training staff on how to use the plans. Update, write, review, and update the continuity of operations plans (COOP) for the three campuses to align with regulatory requirements from TJC and CMS. This includes training staff on how to use the plan. Works with Maintenance (OA-FMDC) and Security on Interim Life Safety Measures for the three campuses to align with regulatory requirements from TJC and CMS. Works with OA-FMDC to determine when fire watches may be needed.

Assists with satellite radio testing. Assists and advices Security and Purchasing with handheld radio purchases and communication equipment. Reviews and/or develops policies or procedures relating to disaster communication, emergency preparedness, fire safety and life safety to align with regulatory requirements from TJC and CMS for the three campuses. Reviews purchase requests that Purchasing forwards because hazardous materials are being requested or there is a fire safety concern or life safety concern. Assist with any special assignments given by supervisor, COO's or CEO. This person is part of the HICS team and acts as an advisor to the HICS team. In the event of an actual disaster or emergency, they are expected to be on grounds at the facility in need. Attends monthly STARRS meetings and reports back to leadership regional emergency planning. Communicates with BJC Fire/Safety person regarding drills at FTC-N that may affect BJC at FTC-N. Works with Patient Safety Officer to develop a Safety Week during healthcare quality recognition week. May participate in committees such as safety committee or leadership committees. Completes a gap analysis on performance and regulatory compliance at least once a year. Provides quarterly data and analysis to leadership on environmental safety issues at the facility. Plans, facilitates, and monitors the FEMA 100, 200, 300 class completion by staff.

Eligibility

Required

1. No discipline within the last 12 months (internal candidates).

2. Bachelor's degree in safety, public health, environmental health, occupational safety, healthcare field or other related field

3. Two (2) years' experience related to workplace safety, environmental science, regulatory compliance, healthcare life safety, or healthcare environment of care.

Preferred

4. Master's degree in safety, public health, environmental health, occupational safety, healthcare field or other related field

5. Four (4) years' experience with healthcare workplace safety, environmental science, TJC or CMS regulatory compliance, healthcare life safety, fire drills in healthcare, environmental disease response in healthcare or healthcare environment of care.

Completion of FEMA courses 100, 200, 300

Excellent State of Missouri Benefits Include:

10 hours of Annual Leave accrued per month

10 hours of Sick Leave accrued per month

13 paid holidays per year

Retirement Plan

Health, Dental, Vision, and Life Insurance eligibility

Why DMH?

The Missouri Department of Mental Health is dedicated to the prevention, treatment, and public understanding of mental illness and developmental disabilities. By joining our team, YOU can make a difference in the lives of those impacted by a mental illness or developmental disability, so they have the opportunity to pursue their dreams, live their lives to the fullest, and be a valued member of their communities.