Quality & Improvement Nurses - Baystate Health

Req#: R27535
Category(s): Nursing, Quality & Improvement Nurses
Full Time / Part Time: Per Diem
Shift: First


Coordinates Quality Management and Performance Improvement programs.   Assists in coordination of Joint Commission compliance activities for quality management, performance improvement, and patient safety.

Job Responsibilities:

1) Systematically performs medical record reviews to collect data to support identified quality measures. Data is entered into appropriate IS systems/web applications to report quality, track quality of care problems and issues, ensuring that communications occur in a highly confidential and timely manner consistent with BWH policy.

Manage, implement, and evaluate performance improvement (PI) clinical studies, including collecting and analyzing data and preparing formal reports for presentation.

Manage the coordination of data collection and reporting of performance improvement (PI) data as needed to meet requirements of third party payers and other external agencies.      

2) Functions as Performance Improvement Team Facilitator for select project teams.  Serve as resource/liaison/educator to all hospital departments, service line teams, medical staff, hospital quality council, regarding performance improvement processes.

Ensures that systems and/or process issues identified during performance improvement activities are referred to appropriate department(s) or teams for resolution.

Utilizes PDSA cycle, lean methodologies, and other quality improvement tools as appropriate in performance improvement activities.   Ensure that documentation of all PI activities is complete, accurate, easily retrievable and current as required by department policy, CMS and Joint Commission. Collaborate and support performance improvement committees to ensure appropriate documentation and issue resolution to maintain full Joint Commission and CMS compliance.    

3) Systematically tracks quality of care problems and issues, ensuring that horizontal and vertical communications occur in a highly confidential and timely manner consistent with BWH policy.

4) Supports hospital peer review processes including medical staff and nursing peer review;  including the comprehensive review of care, trending of issues, timely completion of reviews and implementing identified performance improvement activities. 

5) Collaborate with BH performance improvement colleagues, representing BWH on committees and projects.

6) Maintains a collaborative working relationship with all staff and external contacts.

7) Contributes to day to day functioning of the quality management department. Assists with special projects as assigned.

8) Assumes responsibility for own professional growth and development including attending appropriate educational programs and maintaining clinical knowledge relevant to performance improvements responsibilities.

Required Work Experience:

1) 5 years recent acute clinical nursing.

Preferred Work Experience:

1) None listed.

Skills and Competencies:

1) Ability to organize and prioritize workload to meet deadlines.

2) Demonstrated ability to facilitate performance improvement process.

3) Ability to manage multiple competing priorities.

4) Demonstrated ability to collaborate with all members of the healthcare team.

5) Strong written and oral communication skills.

6) Must possess excellent interpersonal skills.

7) Excellent computer skills to include word processing and database software.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Diploma in Nursing: Nursing (Required)


Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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