RELOCATION ASSISTANCE AVAILABLE!!FacilityBetsy Johnson HospitalLocationDunn, North CarolinaDepartmentQuality & Patient SafetyJob FamilyProfessionalWork ShiftDays (United States of America)SummaryServes as an expert resource to advance Quality and Patient Safety (PS). Supports the management of quality and performance improvement for the organization and its Medical Staff through participation in and coordination of activities related to the acquisition, aggregation, and analysis of relevant data and its use toward improvement of clinical and work processes. Assists in overseeing constant preparedness for Joint Commission, CMS, and other regulatory inspections. Develops, manages, and coordinates the quality, evidence-based care of patients. Strives to ensure evidence-based medicine is used the treatment of patients. Provides education and leadership on patient floors to drive quality metrics in disease specific areas.Major Job FunctionsThe following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:Serves as an educator on the patient floors to help drive quality of care and CMS/Leapfrog metricsWorks with Team Leaders, Facilitators, and Members to provide ongoing education related to process, data analysis and toolsResource in providing monthly reports to the Quality Council/Patient Safety Team, Medical Executive Committee (MEC) and Board of Trustees on Performance Improvement, Patient Safety and RegulatoryCoordinates Hospital wide PI/PS/Regulatory meetings as assignedIdentifies and mitigates patient safety risks and coaches staff/leaders and physicians in safe practicesUses project management tools as needed to interpret dataApplies lean tools and processes to reduce waste in areas of cost, inventory, labor, and distanceCoordinates Root Cause Analyses and Failure Mode and Effect Analyses as assignedDemonstrates knowledge of current Joint Commission and CMS standardsAssists with the tri-annual Joint Commission survey within the organization and CMS and DHSR surveysStays current with CMS and other regulatory standards related to the Core MeasuresAssists multidisciplinary team in developing, implementing, and monitoring systems to ensure transitions of care from acute inpatient phase through follow-up out-patient careParticipates in and supports the Joint Commission DSC process and performance measure complianceEvaluates interdisciplinary care processes ensuring consistency in the standards of care and practiceOther duties as assignedMinimum QualificationsThe following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:Education and Formal Training:Bachelor of Science in Nursing requiredCurrent licensure in North Carolina as a Registered Nurse or Compact state licensureNurse Practitioner NP preferredWork Experience:2 years’ experience in working with Quality/Patient Safety and Regulatory, Quality Process and/or Data AnalysisKnowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languageKnowledge of PI methodologies, Joint Commission and CMS standards, and patient safety issuesKnowledge of quality planning, cost of quality, and importance of documentationKnowledge of basic statistics, distributions, probability, and measurement scaleSkills with the audit process to include audit types as well as audit roles and responsibilitiesSkills in working with teams to include team building techniques and understanding team roles and responsibilitiesAbility to collect, aggregate and review data. Experience with regression and correlation, hypothesis testing, design of experiments (DOE) preferredPhysical Requirements:Ability to move throughout the Health SystemVisual acuity for reviewing data and reports and observing process flowsAudiological acuity for monitoring group discussions and interactionsVerbal ability is required to effectively express ideas and views to staffNo anticipated occupational exposures to bloodborne pathogens or body fluidsMust be able to lift 35 pounds#CFVH-2026Required Licenses and CertificationsRN - Board Of NursingCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity