Reporting to the Director of Quality & Safety, the Quality, Safety & Performance Improvement Specialist supports the advancement of a comprehensive quality, patient safety, regulatory, and patient experience program at Anna Jaques Hospital. Working collaboratively with clinical, operational, and administrative leaders, the Specialist is responsible for coordinating, facilitating, monitoring, and evaluating activities related to quality improvement, performance improvement, patient safety, patient grievances, regulatory compliance, accreditation readiness, and patient experience. This role serves as an internal consultant and resource to departments throughout the organization and supports efforts to improve clinical outcomes, enhance patient experience, reduce organizational risk, and foster a culture of safety, service excellence, and continuous improvement. The Quality, Safety & Performance Improvement Specialist functions as a Quality Department generalist with responsibilities spanning multiple domains of healthcare quality management. This position supports the collection, analysis, interpretation, and reporting of quality and safety data; facilitates improvement initiatives; assists with regulatory readiness activities; and collaborates with multidisciplinary teams to achieve organizational quality, safety, and patient experience goals. The Specialist serves as a resource for quality improvement methodologies, patient safety principles, accreditation standards, and performance excellence practices while promoting a culture of accountability, transparency, patient- centered care, and high reliability throughout the organization. Job Description: ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to): Quality Improvement & Performance Excellence 3 Supports hospital-wide quality improvement and performance improvement initiatives aligned with organizational goals, strategic priorities, and regulatory requirements. 3 Assists departments in identifying opportunities for improvement through data analysis, benchmarking, audits, observations, and performance monitoring activities. 3 Facilitates performance improvement projects utilizing established methodologies such as Plan-Do-Study-Act (PDSA), Lean, Root Cause Analysis (RCA), and Failure Mode and Effects Analysis (FMEA). 3 Collaborates with clinical and operational leaders to develop, implement, and monitor corrective action plans and improvement initiatives. 3 Supports Quality Assessment and Performance Improvement (QAP) activities, documentation, reporting, and performance monitoring. 3 Participates in quality committees, multidisciplinary workgroups, and organizational performance improvement teams. 3 Monitors quality metrics and performance indicators and reports findings to leadership and relevant committees. Patient Safety & Risk Reduction 3 Supports the implementation and coordination of the hospital's patient safety program. 3 Reviews patient safety events, near misses, and incident reports and ensures appropriate follow-up and escalation. 3 Conducts or facilitates event investigations, apparent cause analyses, and root cause analyses as appropriate. 3 Tracks and trends patient safety events to identify opportunities for process improvement and harm reduction. 3 Partners with leaders and frontline staff to implement corrective and preventive actions designed to improve safety outcomes. 3 Supports organizational initiatives related to High Reliability Organization (HRO) principles and safety culture. 3 Assists with patient safety education, communication, and awareness programs. 3 Prepares reports and presentations related to patient safety performance, trends, and improvement initiatives. Patient Experience & Grievance Management 3 Coordinates the investigation, tracking, and resolution of patient complaints and grievances in compliance with federal, state, accreditation, and organizational requirements. 3 Collaborates with patients, families, providers, managers, and staff to ensure timely review and resolution of concerns. 3 Drafts and manages grievance correspondence consistent with regulatory and organizational standards. 3 Maintains grievance documentation and records in accordance with regulatory requirements. 3 Monitors complaint, grievance, and patient feedback trends and reports findings to leadership and quality committees. 3 Identifies recurring themes and opportunities to improve patient experience, communication, and service recovery. 3 Supports organizational patient experience initiatives and patient-centered care strategies. 3 Assists with monitoring and reporting patient experience metrics, including Press Ganey, HCAHPS, and other patient satisfaction measures. Regulatory Compliance & Accreditation Readiness 3 Supports organizational readiness for regulatory, accreditation, and licensing surveys. 3 Participates in mock surveys, tracers, audits, and compliance assessments throughout the organization. 3 Assists departments in addressing regulatory findings and implementing corrective action plans. 3 Monitors compliance with The Joint Commission standards, CMS Conditions of Participation, Massachusetts Department of Public Health regulations, and organizational policies. 3 Maintains documentation supporting regulatory and accreditation compliance activities. 3 Assists with survey preparation, coordination, response activities, and follow-up actions. 3 Serves as an internal resource regarding quality, patient safety, patient rights, and regulatory requirements. Data Analytics & Reporting 3 Collects, validates, analyzes, and interprets quality, patient safety, patient experience, grievance, and performance improvement data. 3 Develops reports, dashboards, scorecards, summaries, and presentations for leadership and organizational committees. 3 Supports required quality reporting activities for internal and external stakeholders. 3 Identifies trends, performance gaps, risks, and opportunities for improvement through data analysis and benchmarking. 3 Maintains quality databases, reporting systems, and performance monitoring tools. 3 Assists in preparation of reports required by organizational leadership, committees, regulatory agencies, and external quality programs. Education, Consultation & Collaboration 3 Provides consultation and support to departments regarding quality improvement, patient safety, patient experience, grievance management, and regulatory compliance activities. 3 Assists in the development and delivery of educational programs related to quality, safety, accreditation, performance improvement, and patient experience. 3 Supports organizational committees through meeting preparation, data reporting, follow-up, and documentation. 3 Facilitates collaboration among clinical and operational departments to achieve quality and patient safety goals. 3 Participates in special projects and organizational initiatives as assigned. 3 Performs other duties as requested or required. QUALIFICATIONS: Education 3 Bachelor's degree in Nursing, Healthcare Administration, Public Health, Health Sciences, Quality Management, or related healthcare field required. 3 Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or related field preferred. Experience (preferred) 3 Minimum of 1-3 years of experience in healthcare quality, patient safety, performance improvement, risk management, patient relations, regulatory compliance, accreditation, or related healthcare operations. 3 Acute care hospital experience required. 3 Experience supporting quality improvement, regulatory readiness, patient safety, or patient experience initiatives preferred. PREFERRED CERTIFICATIONS: 3 Certified Professional in Healthcare Quality (CPHQ) 3 Certified Professional in Patient Safety (CPPS) 3 Lean, Six Sigma, or related Performance Improvement certification 3 State of Massachusetts Registered Nurse (RN) licensure (required) OTHER REQUIREMENTS: 3 Knowledge of healthcare quality management principles and performance improvement methodologies. 3 Working knowledge of patient safety, risk reduction, and quality improvement tools and techniques. 3 Knowledge of CMS Conditions of Participation, The Joint Commission standards, Massachusetts Department of Public Health regulations, and other applicable regulatory requirements. 3 Understand Quality Assessment and Performance Improvement (QAPI) principles and practices. 3 Strong analytical, organizational, and problem-solving skills. 3 Ability to interpret, analyze, and communicate complex performance and quality data. 3 Excellent interpersonal, relationship-building, and collaboration skills. 3 Strong written and verbal communication skills. 3 Ability to facilitate multidisciplinary teams and lead improvement projects. 3 Ability to manage multiple priorities and meet deadlines in a fast-paced healthcare environment. 3 Proficiency in Microsoft Office applications, including Excel, Word, PowerPoint, and reporting tools. 3 Ability to maintain confidentiality and exercise sound professional judgment. 3 Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values. 3 Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment Physical & Environmental Requirements This position requires frequent sitting, standing, walking, computer use, and participation in meetings throughout the organization. The incumbent must be able to travel throughout hospital departments and affiliated locations and participate in audits, surveys, investigations, and committee activities as needed. Work is performed in a combination of office and healthcare environments with frequent interaction with physicians, staff, patients, families, hospital leaders, and external regulatory representatives. Occasional schedule flexibility may be required to support investigations, surveys, meetings, or organizational priorities. Competencies 3 Patient Safety Focus 3 Quality Improvement Methodology 3 Performance Excellence 3 Patient Experience & Service Recovery 3 Data Analysis & Interpretation 3 Regulatory & Accreditation Knowledge 3 Critical Thinking & Problem Solving 3 Project Management 3 Collaboration & Teamwork Pay Range: $85,000.00 USD - $110,000.00 USD The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.