Job Description

Location: St. Elizabeth's Medical Center
Posted Date: 10/28/2022

Manager, Quality/PI – Quality & Safety – 40 hrs/wk (Days) | No Weekends or Holidays | RN Required

At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized behavioral health care with dignity, compassion and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.

We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.

In support of this, we commit ourselves to the following values:






If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.


(Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?)

  • Under the general supervision of the Director of Quality/Risk & Patient Safety, with latitude for independent initiative and judgment, the Performance Quality Improvement Specialist is a central figure in the hospital-wide quality initiative programs. He/she is responsible in assisting the Director of Quality/Risk & Patient Safety with the development and implementation of hospital-wide quality and safety programs. Assists in leading the organization in implementing QI programs that include measures for effectiveness
  • The /Quality Improvement Specialist is directly accountable to the Director of Quality/Risk & Patient Safety and has a collaborative relationship with Corporate Quality.
  • The Quality Improvement Specialist has the responsibility to educate all levels of nursing personnel and other health care workers and hospital staff regarding performance improvement and quality improvement processes and practices.
  • Occasional travel off-site required. Must be available by pager during work hours.


(Use bullets for specific responsibilities)

  • Attends hospital meetings where measurement and evaluation functions, or performance improvement/quality activities are performed or as directed by the Director of Quality/Risk and Patient Safety.
  • Designs and implements quality improvement initiatives/programs and serves for a project manager for designated projects/programs.
  • Identifies opportunities for improvement using data and reporting mechanisms
  • Coordinates and reviews data elements for all quality measures identified including data collection, analysis, and reporting, identify areas for improvement and then coordinating efforts to improve performance.
  • Serves as liaison to corporate, statewide and national collaborative for quality and performance improvement initiatives.
  • Serves as hospital’s oversight for policy development and corporate policy conversion as Policy Coordinator.
  • In collaboration with the Director of Quality/Risk & Patient Safety, serves as departmental advisor for the interpretation and compliance monitoring with The Joint Commission (TJC) and relevant Regulatory Agencies.
  • Assists in the coordination of Joint Commission or other regulatory site survies, prepares the organization for ongoing readiness. Educates staff of regulatory standards,
  • Under the direction of the Director of Quality/Risk Patient Safety, assists and/or conducts root cause analysis (RCA) which may include coordination of medical information, debriefing of involved individuals, performing cause and effect analysis, coordinating an expert panel review, root solution, and follow-up initiatives.
  • Under the direction of the Director of Quality/Risk Patient Safety conducts failure mode and effects analysis (FMEA) when high volume, high risk opportunities are discovered. Organizes a team, creates process maps, creates failure modes analysis, identify prevention and/or corrective action strategies.
  • Conducts Orientation and educational programs for staff as directed.
  • Assists in the preparation of reports and presentations as required/directed.
  • Leads or participates in related committees: Quality and Patient Safety, PSTT, Falls, HAC, P&P, Infection Control, various workgroups.
  • Assists in the management of quality data, with analysis and reporting. (Adverse Events, HAC, DPH, DMH etc.)
  • Provides education and support for units/departments/staff on, methods tools and techniques for monitoring and assessing quality of care and compliance with Joint Commission and other Quality, High Reliability and regulatory requirements.Accountable for maintaining the confidentiality and security of all hospital-related, medical staff-related and patient-related data and information.
  • Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and safe environment.
  • Commits to recognize and respect cultural diversity for all customers (internal and external).
  • Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
  • Performs other duties as assigned.


(Examples: Ability to work independently and take initiative; Good judgment and problem-solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality)

  • Strong organizational skills and ability to work independently.
  • Excellent oral and written communication skills
  • Ability to work on diverse teams, multitask and manage multiple projects
  • Maintains expertise with Joint Commission, DPH, DMH, CMS standards and survey process.
  • Strong interpersonal skills, ability to work across disciplines.
  • Ability to analyze data and formulate meaningful information.
  • Ability to work with, develop, and motivate multidisciplinary teams.
  • Strong orientation to patient care in accordance with the Medical Center’s values.
  • Ability to work with highly sensitive and confidential information, with appropriate discretion.


  1. Education: RN required. Master’s Degree in Healthcare, Public Health or closely related field required
  2. Experience (Type & Length): Minimum of 2-3 years in hospital quality/performance improvement. Working knowledge of Joint Commission, LEAN, RCA, and FMEA concepts, strongly preferred.
  3. Certification/Licensure: RN required. Master’s degree required. CPHQ certification preferred.
  4. Software/Hardware: Working knowledge of Microsoft Office required. Knowledge of Press Ganey, QNet, rlSolutions, MCN Policy Manager, and Meditech preferred.
  5. Other:

Additional Information

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

Important COVID message

Please note, St. Elizabeth's Medical Center is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence, and convenience: Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled, and professional way.

This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.

Application Instructions

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