- Salary
- $80k – $143k
- Location
- GBMC Hospital, United States of America
- Type
- Full-time
- Department
- Healthcare
- Seniority
- Lead
- Source
- Workday
Description
Education:
Bachelor’s degree in nursing, Healthcare Administration, Public Health, Health Sciences, or a related healthcare field required, or an equivalent combination of education and relevant healthcare experience.
Master’s degree preferred.
Experience:
- 3- 5 years of progressive experience in healthcare quality, patient safety, performance improvement, accreditation, regulatory compliance, physician peer review, or related healthcare quality functions.
- Demonstrated experience independently leading complex quality improvement initiatives, patient safety event analyses, and multidisciplinary teams.
- Experience facilitating Root Cause Analyses (RCA), Apparent Cause Analyses (ACA), Failure Mode and Effects Analyses (FMEA), or other structured improvement methodologies.
- Demonstrated ability to provide consultation and coaching to clinical and operational leaders regarding quality improvement, patient safety, and performance improvement strategies.
- Experience presenting findings, recommendations, and improvement strategies to multidisciplinary audiences, physician leaders, and executive leadership.
Preferred
- Experience serving as a technical resource or mentor to other quality professionals.
- Experience supporting physician peer review and professional practice evaluation processes.
- Experience utilizing healthcare quality data, benchmarking, and performance measurement to guide improvement efforts.
- Experience within an acute care hospital or integrated health system.
Licensures and Certifications:
RN or other licensed healthcare professional preferred
Professional certification in healthcare quality, patient safety, healthcare risk management, Lean Six Sigma, or another relevant discipline (e.g. CPHQ, CPPS, CPHRM) required
OR Certification must be obtained within two years of hire if not held at the time of appointment.
Skills:
- Knowledge of healthcare quality, patient safety, regulatory, and accreditation standards (e.g., CMS, The Joint Commission, Maryland quality programs).
- Experience applying quality improvement and patient safety methodologies, including Lean, PDSA, Root Cause Analysis (RCA), and Failure Mode and Effects Analysis (FMEA).
- Proficiency using Epic, Microsoft Excel, PowerPoint, and Word to analyze data, prepare reports, and communicate findings.
- Experience interpreting clinical quality and patient safety data from sources such as Epic, Premier, or other healthcare analytics platforms.
- Ability to facilitate multidisciplinary meetings, provide consultation on quality and patient safety initiatives, and educate clinical teams.
- Strong written and verbal communication skills with the ability to present data and recommendations to leaders, physicians, and frontline staff.
- Strong organizational and project management skills with the ability to manage multiple priorities and meet deadlines.
Principal Duties and Responsibilities:
• Serves as the department’s advanced technical resource, providing expert consultation and guidance on patient safety, quality improvement, physician peer review, and organizational learning.
• Independently leads complex quality and patient safety initiatives, applying advanced knowledge of improvement science, patient safety methodologies, and systems thinking to support organizational priorities.
• Serves as a trusted consultant to physicians, nursing leaders, operational leaders, and interdisciplinary teams, providing recommendations that improve quality, patient safety, and clinical outcomes.
• Builds technical capability across the organization by coaching leaders and colleagues in patient safety science, quality improvement methodologies, and evidence-based improvement strategies.
• Independently facilitates complex Comprehensive Systematic Analyses, including Root Cause Analyses (RCA), Apparent Cause Analyses (ACA), Failure Mode and Effects Analyses (FMEA), and other structured event analyses.
• Conducts comprehensive event investigations, chart reviews, timeline analyses, and system assessments to identify contributing factors and opportunities for organizational learning.
• Applies independent professional judgment to recommend appropriate event analysis methodologies while recognizing situations requiring collaboration or escalation to department leadership.
• Develops meaningful, sustainable corrective actions and collaborates with operational leaders to evaluate implementation and effectiveness.
• Leads complex multidisciplinary quality improvement initiatives using structured improvement methodologies, including the Model for Improvement, PDSA, Lean, and other evidence-based approaches.
• Partners with operational leaders to identify system opportunities, translate performance data into actionable improvement strategies, and facilitate sustainable organizational change.
• Coaches clinical and operational leaders in the practical application of improvement science, patient safety principles, systems thinking, and high reliability concepts.
• Promotes organizational learning by identifying recurring system issues, sharing lessons learned, and supporting the standardization of successful improvement practices.
• Coordinates complex physician peer review activities, ensuring timely case review, meaningful clinical analysis, and effective communication with physician leaders.
• Supports Medical Staff leadership through objective case analysis, preparation of peer review materials, and facilitation of peer review discussions.
• Identifies opportunities for system improvement through peer review findings and collaborates with leaders to strengthen quality and patient safety.
• Facilitates multidisciplinary workgroups, improvement teams, patient safety reviews, and project teams to achieve measurable organizational improvement.
• Presents quality, patient safety, physician peer review, and performance improvement findings to physicians, nursing leaders, executives, committees, and governing bodies as appropriate.
• Communicates complex quality and patient safety concepts in a manner that promotes shared understanding, engagement, and accountability.
• Builds trusted relationships across the organization through professionalism, technical expertise, collaboration, and responsive consultation.
• Analyzes quality, patient safety, physician peer review, and performance data to identify trends, prioritize improvement opportunities, and evaluate intervention effectiveness.
• Develops meaningful reports, presentations, and recommendations that support operational and executive decision-making.
• Supports organizational quality reporting and performance measurement activities as assigned.
• Collaborates with the Manager and department leadership to advance departmental priorities, strengthen standard work, and promote consistent application of quality and patient safety methodologies.
• Provides consultation, collaboration, and informal coaching to colleagues by sharing technical expertise, modeling best practices, and fostering a culture of continuous learning.
• Maintains current knowledge of emerging evidence, regulatory expectations, patient safety science, and improvement methodologies to support organizational excellence.
• Provides cross-coverage for other departmental functions as needed to ensure continuity of operations.
All Roles Must Follow GBMC Values:
Respect
- Treats others with fairness, kindness, and respect for personal dignity and privacy
- Listens and responds appropriately to others’ needs, feelings, and capabilities
Excellence
- Meets and/or exceeds customer expectations
- Actively pursues learning and self development
- Pays attention to detail; follows through
Accountability
- 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
- 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
- Demonstrates honesty, integrity and good judgment
- Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers
Results
- 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
$79,517.04 - $143,130.67Final 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.