Quality Patient & Safety Advisor – Procedural Services

Cape Cod Healthcare Inc.; Hyannis (MA); On-site; USD 81,000 - 105,000; Full time

Job summary

Cape Cod Hospital in Hyannis, MA seeks a QPS Advisor – Procedural Services to support regulatory compliance, patient safety, and continuous improvement across operating rooms, PACU, endoscopy, and other procedural settings.

You will monitor quality data, prepare dashboards and reports, track trends, and present findings to leaders and interdisciplinary teams. A BSN and 3 years perioperative nursing experience are required; strong communication and confidentiality are essential.

Qualifications

• Graduate of a school of nursing with a BSN.
• Minimum three years of perioperative or procedural nursing experience.
• Ability to work independently and maintain confidentiality.
• Strong English and communication skills; able to manage change and stay focused.

Responsibilities

• Monitor quality metrics and KPIs for procedural services and related areas.
• Collect, validate, analyze, and maintain quality data.
• Prepare monthly, quarterly, and other quality reports and dashboards.
• Track trends related to complications, infection prevention, patient experience, and other indicators.
• Present findings and recommendations to department leadership and teams.
• Maintain documentation of audits, findings, and outcomes of improvement activities.
• Assist with development, implementation, and monitoring of dashboards.
• Support QI initiatives using PDSA, root cause analysis, and process mapping.
• Review criteria and nursing guidelines when applying clinical judgments; monitor regulatory requirements.

Skills

Communication skills

Time management

Confidentiality

Independent work

Team orientation

Education

BSN

Nursing degree

Tools

Microsoft Word

Outlook

Excel

Internet

Job description

Purpose of Position: The QPS Advisor – Procedural Services provides guidance and operational support to promote regulatory compliance, patient safety, clinical quality, and continuous performance improvement across procedural areas of the hospital. The position partners with procedural leadership, physicians, nurses, anesthesia providers, and multidisciplinary teams to monitor clinical outcomes, identify safety risks, evaluate compliance with regulatory and accreditation standards, and implement sustainable improvement initiatives. Procedural areas may include the operating room, post-anesthesia care unit (PACU), endoscopy, OB/GYN, and other invasive or diagnostic procedural settings. The Advisor supports hospital-wide quality and patient safety programs, facilitates event reviews and root cause analyses, monitors corrective action plans, and promotes a culture of safety, accountability, and high reliability.

Quality Assurance and Performance Improvement

• Monitor quality metrics and key performance indicators (KPIs) for procedural services, such perioperative services, OB/GYN and other designated procedural areas.
• Collect, validate, analyze, and maintain quality data for procedural services.
• Prepare monthly, quarterly, and other quality reports, dashboards, and performance summaries.
• Track trends related to complications, infection prevention, patient experience, and other department-specific indicators.
• Present findings and recommendations to department leadership, quality committees, and interdisciplinary teams.
• Maintain accurate documentation of audits, findings, improvement activities, and outcomes.
• Assist with the development, implementation, and monitoring of dashboards
• Support continuous quality improvement initiatives using methodologies such as Plan-Do-Study-Act (PDSA), root cause analysis, and process mapping.
• Make clinical judgments based on evidence-based standards of care, review criteria and nursing practice guidelines when applicable
• Monitor compliance to applicable regulatory and accreditation/certification program requirements including PRO/PM measures and the Joint Commission DSC certifications.
• Manage surgical related registries including BCBS for total joint replacement and spine surgery.

Qualifications

EDUCATION/EXPERIENCE/TRAINING

• Graduate of a school of nursing
• (BSN) – A Bachelor of Science in Nursing
• Three years prior nursing experience in perioperative or procedural areas.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.
• Must be able to demonstrate and promote a positive team-oriented environment.
• Must be able to stay focused and concentrate under normal or heavy distractions.
• Must be able to work well under pressure and/or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately
• Must have strong knowledge of medical terminology, anatomy and physiology, medications, and laboratory values.
• Must be able to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation, and style.
• Ability to follow instructions and respond to upper management’s directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.

• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively, and asking questions where clarification is needed.
• Position requires long periods of time working on a computer

Schedule Details

4 Day Work Week, Monday-Thursday, No Weekends, & No Holidays

Organization: Cape Cod Hospital

Primary Location: Massachusetts-Hyannis

Department: CCH-Quality / Patient Safety

Annual/Hourly: Annual - Based on Full Time Employment

Hiring Pay Range: 81100 - 105000