CommonSpirit Health
Job Summary and Responsibilities
This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and for identifying opportunities to improve patient care, incorporate evidence‑based practices, and enhance patient outcomes. It provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.
Key Job Responsibilities
Establish performance improvement goals annually with relevant stakeholders and ensure that the PI plan and the hospital‑focused projects for the year are implemented and evaluated annually.
Facilitate a multidisciplinary approach to performance improvement and foster participation in all initiatives to share and learn best practices.
Develop and implement processes and formats that support data collection, aggregation, analysis, and action planning; assure data is managed appropriately and disseminated to appropriate leadership staff.
Provide leadership in developing quality improvement training programs and coach organizational clinical/service lines and operational/support departments in quality improvement principles.
Collaborate with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing practitioner evaluation.
Ensure compliance and provide leadership and oversight for accreditation, licensure and regulatory survey readiness; conduct mock survey tracers, educate staff and providers on regulatory compliance, identify areas of opportunity and corresponding actions for compliance, organize required staff to develop responses to survey deficiencies and oversee response submissions to the appropriate accreditation or regulatory agency.
Maintain overall accountability for the assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
Job Requirements Education and Experience Requirements
Bachelor's degree in a healthcare‑related field or five (5) years of related job or industry experience in lieu of a degree.
Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
Minimum of two (2) years of clinical, patient care experience or equivalent.
Required Licensure and Certifications
Current State License in a clinical field.
Five (5) years’ experience in Quality Management can be used in lieu of state license.
Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Where You'll Work Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved through strategic partnerships and integrations to expand our reach and services across the Puget Sound area. We remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. Our providers offer a full spectrum of healthcare services, from routine wellness to complex disease management, grounded in rigorous research and education. Our network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our commitment to accessibility and comprehensive care.
Pay Range $60.24 - $89.60 /hour
Seniority Level Not applicable
Employment Type Full‑time
Job Function Quality Assurance and Health Care Provider
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Key Job Responsibilities
Establish performance improvement goals annually with relevant stakeholders and ensure that the PI plan and the hospital‑focused projects for the year are implemented and evaluated annually.
Facilitate a multidisciplinary approach to performance improvement and foster participation in all initiatives to share and learn best practices.
Develop and implement processes and formats that support data collection, aggregation, analysis, and action planning; assure data is managed appropriately and disseminated to appropriate leadership staff.
Provide leadership in developing quality improvement training programs and coach organizational clinical/service lines and operational/support departments in quality improvement principles.
Collaborate with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing practitioner evaluation.
Ensure compliance and provide leadership and oversight for accreditation, licensure and regulatory survey readiness; conduct mock survey tracers, educate staff and providers on regulatory compliance, identify areas of opportunity and corresponding actions for compliance, organize required staff to develop responses to survey deficiencies and oversee response submissions to the appropriate accreditation or regulatory agency.
Maintain overall accountability for the assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
Job Requirements Education and Experience Requirements
Bachelor's degree in a healthcare‑related field or five (5) years of related job or industry experience in lieu of a degree.
Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
Minimum of two (2) years of clinical, patient care experience or equivalent.
Required Licensure and Certifications
Current State License in a clinical field.
Five (5) years’ experience in Quality Management can be used in lieu of state license.
Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Where You'll Work Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved through strategic partnerships and integrations to expand our reach and services across the Puget Sound area. We remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. Our providers offer a full spectrum of healthcare services, from routine wellness to complex disease management, grounded in rigorous research and education. Our network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our commitment to accessibility and comprehensive care.
Pay Range $60.24 - $89.60 /hour
Seniority Level Not applicable
Employment Type Full‑time
Job Function Quality Assurance and Health Care Provider
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