Description Essential Functions Performance Improvement & Change Management * Review care of patients (concurrent and retrospective) to assess for complications of care and adherence to published practice standards * Liaison with the physicians, nurses and ancillary staff regarding Quality and Patient Safety, and other quality/risk initiatives, including publically reported indicators * Develops performance improvement activities as defined by organizational priorities * Attends departmental meetings, as assigned, to serve as Quality Institute representative and subject matter expert. * Performs tracer activity to assure compliance with all regulatory standards. * Serves as coach and mentor to staff regarding regulatory and other initiatives defined in Quality & Safety priorities * Communicates opportunities for improvement to unit/departmental leadership as identified. * Facilitates communication with leadership on organizational opportunities for improvement at unit or department level Patient Safety * Collaborates with Manager and Quality Institute Leadership in identifying annual priorities as it impacts Patient Safety * Supports an effective Patient Safety Program for this facility based on the current priorities * Participates in Performance Improvement activity related initiatives to positively impact Patient Safety and Reduction of Adverse Events * Assists in identifying best practices and process redesign to improve patient safety Accreditation & Regulatory Compliance * Assists with organization wide continuous accreditation readiness and continuous regulatory compliance, including a proactive tracer program * Maintains data collection to support and drive accreditation functions * Actively participates in process improvement initiatives to improve compliance with accreditation standards * Under direction of manager / administrator disseminates data and feedback on compliance with accreditation standards to all stakeholders * Participates with UH Accreditation team to enhance monitoring, promote needed practice changes and improve compliance system wide. * Is actively engaged in review of updates to accreditation standards (CMS, TJC, & Specialty) and timely communication of changes to involved stakeholders. * Under the direction of manager, assists with TJC extranet site for hospital, shares TJC communications and monitors for any scheduled or unscheduled visits. Provides feedback as required to TJC via secure site. Patient Advocacy * Concurrent monitoring for compliance of standards identified as JC/CMS Grievance and/or patient complaints, and any other identified organizational priority * Performs rounding and interview of patients and their families to assure that organizational expectations for the patient experience are met. * Queries the patients, medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete documentation that supports compliance with JC/CMS standards on follow-up to grievances and patient complaints * Data management including collection, entry, trending and analysis to support performance improvement. Ability to summarize and analyze clinical and operational data, develop summary reports, charts, and graphs, trend outcomes, and identifies opportunities for improvement from the data analyses. * Consistently demonstrates ability to identify issues and collaborative problem-solving. Serve as a liaison between patients, front-line staff, Performance Improvement committees and leadership in order to elicit opportunities for improvement and identify barriers to success in meeting Risk/Safety/Advocacy Priorities. * Participates in performance improvement as directed. Work in collaboration with the Quality Improvement, Risk, Legal and clinical staff in the Quality Institute. * Collaborates with the Quality Institute staff and UH sys