Quality & Patient Safety Specialist - Ambulatory

The Quality and Patient Safety Specialist supports the organization in advancing high‑reliability and a culture of safety. Under general supervision, this role provides leadership, guidance, and subject‑matter expertise to ambulatory clinical and operational teams to ensure compliance with policies, accreditation standards, and patient safety requirements. In general, the specialist oversees and/or facilitates quality and patient safety activities, including safety event review and analysis, patient experience and complaint resolution, emergency preparedness, performance improvement initiatives, Comprehensive Systematic Analyses, and physician peer review coordination. The specialist will participate in accreditation readiness activities, site visits, action planning, and monitoring sustainability.

Education

• Bachelor’s degree in nursing, Public Health, Healthcare Admin., or other related field preferred; formal Performance Improvement training preferred

Experience

• A minimum of 2 years’ experience in outpatient healthcare settings preferred.
• Experience with quality improvement, patient safety, and action planning

Knowledge, Skills and Abilities

• 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, 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. 
• Skill in providing consultation, coaching, and support to clinical and non-clinical 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.
• Ability to manage multiple assignments and effectively organize and prioritize workload
• Strong working knowledge of outpatient clinical processes

Licensures, Certifications

• Current Maryland clinical certification (CMA) or license(RN or LPN) preferred
• Lean Six Sigma Green Belt (LSSGB) within 1 year, Certified Professional in Patient Safety (CPPS) within 2 years
• MD driver’s license

Physical Requirements

• Able to perform audits in a clinical setting, which include long periods of standing, walking and bending

Working Conditions

• Normal office work environment, hospital and medical office locations
• Ability to travel to multiple office locations/must have reliable transportation

Principal Duties and Responsibilities

• Participates and assists during onsite accreditation or program survey site visits and delegated credentialing audits.
• Conducts orientation of new employees related to quality and patient safety.  Provides on-going staff education and support as it relates to High Reliability principles and patient safety.
• Regularly rounds on assigned practices and departments ensuring a collaborative relationship with those areas’ leaders and staff and conduct proactive environmental surveillance. Prepare surveillance activity reports and assign/monitor action plans for completeness and sustainability.
• Reviews safety events from the incident reporting system as assigned and triages appropriately for potentially compensable events and reportable events.  Ensure event follow-up documentation is thorough and prepares analysis of events and action items.
• Facilitate Comprehensive Systematic Analyses as designated by the Risk Prioritization Matrix to identify the root cause(s). Ensure 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 outpatient care settings, translating performance data into targeted improvement strategies that align with organizational priorities and regulatory and/or program requirements (Vaccine for Children, CLIA Waived Testing, CMS, TJC, ACS Quality Improvement programs, MDPCP, and other Value-Based programs).
• 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, 5S.   Support strategy and practice level huddle boards using Lean principles and provide training to staff.
• Makes appropriate decisions about the need for physician peer review and facilitates timely physician peer review. Responsibilities may include setting the agenda; taking minutes; preparing, assigning, and tracking cases/indicators; communicating findings and recommendations to relevant committees and/or the Medical Board.
• Support patient experience through CG CAHPS data analysis and proactive staff customer service education. Serve as a patient advocate. Manages the Grievance process with a goal of reaching a mutual resolution between the complainant and the organization.
• Prepare meeting agenda and minutes and facilitate meeting as assigned. Ensure thorough investigations are conducted and tracks

• action plans and measures of success.

• Develop and support Emergency Preparedness initiatives through proactive surveillance, drills, and analysis.
• Support policy development and ensure organizational policies are reviewed and updated as indicated. Provide education to staff and leaders regarding policy management and monitor for adherence.
• Share the learning broadly from actual and near miss events using story telling techniques.

All roles must demonstrate GBMC Values:

Respect

I will treat everyone with courtesy. I will foster a healing environment.

• Treats others with fairness, kindness, and respect for personal dignity and privacy

• Listens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

• Meets and/or exceeds customer expectations

• Actively pursues learning and self-development

• Pays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

• Sets a positive, professional example for others

• Takes ownership of problems and does what is needed to solve them

• Appropriately plans and utilizes required resources for various job duties

• Reports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

• Works cooperatively and collaboratively with others for the success of the team

• Addresses and resolves conflict in a positive way

• Seeks out the ideas of others to reach the best solutions

• Acknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

• Demonstrates honesty, integrity and good judgment

• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

• Embraces change and improvement in the work environment

• Continuously seeks to improve the quality of products/services

• Displays flexibility in dealing with new situations or obstacles

• Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

$58,488.99 - $93,582.39

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.