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Senior Healthcare Quality Improvement Specialist

Job Code


Basic Function

Facilitate and educate multiple organizational teams on the concepts of performance and process improvement; consult with all levels of the organization on process improvement opportunities to cultivate the culture of patient safety; present findings at a variety of forums (meetings, seminars); represent PI on hospital committees.


 All organizational service lines; inpatient units; outpatient units; Districts.

Principal Contacts

All quality department staff members, organization physicians, nursing staff, other health and allied health staff.

Principal Duties

Facilitate and educate multiple organizational teams on the concepts of performance and process improvement; consult with all levels of the organization on process improvement opportunities to cultivate the culture of patient safety; present findings at a variety of forums (meetings, seminars); represent PI on hospital committees.

Improvement Science Methods and Approaches

  • Evaluate performance and process improvement (PPI) methods (Lean, Six Sigma, Plan-Do-Check-Act, and Business Process Management) and apply those best suited to achieving successful clinical outcomes. Use evidence-based, structured methods for all PPI projects. Translate evidence-based and research knowledge into practice to improve outcomes.
  • Use a range of quality improvement tools and techniques (5 Whys, Value Stream Mapping, Failure Mode Effects Analysis, and Root Cause Analysis) and evaluate the output to successfully redesign processes toward improved performance.  Employ an appropriate method based on the structure and purpose of the project.  Identify and use quality improvement tools and techniques throughout the project. Evaluate and integrate the output of findings into the redesign of the process. 
  • Access and use information resources (electronic health records, registries, comparative and benchmark data, and published research) to demonstrate current practice, identify opportunities for improvement, and strive toward improved outcomes.  Identify sources of valid and reliable information and metrics to monitor performance trends.  Analyze and integrate information from disparate information sources to design solutions. Analyze comparative data, benchmarks, and best practices for possible adaptation into the organization, if culturally and practically appropriate.  Use valid data to support opportunity recommendations and illuminate key trends for stakeholders to identify, define, and design solutions to address opportunities based on benchmarking, goal comparison, data analysis, and corrective actions.   
  • Demonstrate expertise in the use of analytical and statistical tools and techniques (hypothesis testing, statistical process control, distribution, and control charts) to identify when, where, and how to measure processes and systems and make decisions supported by data.  Understand how process goals are established, monitored, and measured. Understand the concept of statistical process control, and apply techniques and use tools to identify variation and its causes.
  • Communicate PPI priorities and results using narrative and visual tools (graphs, dashboards, and scorecards), providing a comprehensive context appropriate to the audience.  Select and create specific visualizations (bar graphs, run charts, or pie charts) to ensure accurate and valid interpretation of findings.  Develop basic dashboards and scorecards used to show internal data and benchmark comparisons.  Create and present written and verbal communications that tell a story and are appropriate to the audience’s needs.

Principal Duties (cont'd)

Performance and Process Improvement Project Management

  • Define the need, expected benefits, and alignment of clinical PPI projects to the organizational mission, vision, values, strategic goals, and business priorities. Develop a project plan/scope document ensuring active executive sponsorship, the identification of stakeholders, and alignment of the organization’s mission, vision, goals, and business priorities and goals.

    Design the project plan including an opportunity statement, goals, scope, timeline, and critical milestones utilizing project management methodologies, performance measurements, and tools. Provide project coordination through a variety of project management tools and methods (charters, communication plans, Gantt charts, risk assessment, logic models, process flow diagrams, and action plan templates).  Develop a project plan within the requirements of the charter, including project assumptions and constraints, in alignment with the organization’s mission and vision and establishing the total scope of the effort. Define measurement, establish a baseline, and refine the objectives. Develop a work breakdown structure to outline the course of action required to attain those objectives.  Estimate costs and determine budget.  Conduct preliminary and ongoing risk analysis and mitigate barriers.  Review and incorporate best-practice, evidence-based, or established organization guidelines around proposed interventions.  Prepare a plan for change management. 

    Manage the work defined in the project plan/scope document to ensure the project moves forward according to the project plan goals and timelines. Coordinate people and resources and perform the activities of the project in accordance with the project plan. Identify and utilize clinical tools (clinical practice guidelines, pathways, and algorithms) as deemed appropriate.

    Understand the stages of team formation. Design team activities to maximize engagement using a range of methods for facilitating group interaction. Establish effective and transparent ground rules for team communications and interaction. Maintain a focus on vision, strategy, and achieving desired results throughout the facilitation process.  Facilitate groups to attain consensus and achieve identified shared goals.

    Track, monitor, and communicate project progress to all stakeholders and provide alerts to the project sponsor when deviations from the plan occur. Use and maintain action plans, project charters, timelines, and deadlines to drive accountability and structure related to performance improvement project. Develop and communicate the status of the project and corrective action plans to the sponsor, team members, and stakeholders when the performance improvement project is not meeting timeframes. Adapt the project plan to new information, changing conditions, and unexpected obstacles. Use organizational change control procedures to change the approved project plan. Close the project and hand off the control plan to the process owner for ongoing monitoring and to ensure sustained results.

Principal Duties (cont'd)

Culture and Process Change Management

  • Promote a culture of continuous improvement that leads to sustained results and optimal performance.  Demonstrate knowledge of and the ability to apply a change management model or framework. Demonstrate proficiency in the use of widely accepted change management tools and techniques. Debrief, provide constructive feedback, and recognize and acknowledge positive team interactions, key milestones, and closure of the project with stakeholders and customers. Help others see improvement as a normal component of daily work.
  • Communicate the vision, expectations, and results of PPI clearly, consistently, and appropriately to stakeholders.  Demonstrate the ability to adapt communication styles and human factor approaches and methods to best engage stakeholders.  Create an analysis of project stakeholder acceptance, influence, and resistance to strategic objectives and implement approaches to leverage or increase support.  Articulate the impact of change on stakeholders, processes, systems, organizational structure, and job roles.  Encourage change within the sphere of influence and spread innovation as appropriate. 
  • Use meaningful measurement tools to prove the need for improvement, make changes, and measure return on investment.  Identify meaningful measures and outcomes.  Understand and explain the origin, reliability, validity, and accuracy of data; how data is verified; and the sources used for benchmarking and comparison.  Optimize timely decision through the analysis of information and development of alternative hypotheses and action plans.  Aid effective interpretation and communication of data and information by using visual display techniques. 
  • Provides other duties and responsibilities as assigned by team leader and Process Improvement supervisor.


  • Bachelor’s Degree in Nursing or related healthcare field required
  • Master’s degree in Nursing or related healthcare field  is preferred


Minimum 8 years’ experience, successfully facilitating teams through process improvement projects

Certification/Other requirements as applicable

  • Professional Certification in applicable area required (CPHQ, (CPHQ, Lean or Six Sigma Certification, Project Management Certification.)
  • Knowledge of medical terminology, diagnosis, and basic disease processes.
  • Knowledge of Microsoft office suite applications.
  • Possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the healthcare team.
  • Demonstrates competency in one domain of healthcare quality and safety