Job Summary: The Quality and Patient Safety Specialist is responsible for the development, evaluation, and implementation of evidence-based medicine to improve the safety and quality of care and services organization-wide. Leads activities to assess compliance with and variance evaluation of the organization-wide measurement systems. Provides data for designated quality and safety committees as directed. Demonstrates data collection expertise for all mandatory national hospital quality measures project. Facilitates process and quality improvement and functions as a consultant and coach, providing education to medical staff, nursing, and ancillary services for new and current quality reporting requirements. Participates in and guides performance improvement activities including review of policies and procedures, guidelines, standing orders, clinical pathways, and other documents that are needed for regulatory mandates and clinical procedures. Assists with regulatory visits at all facilities as needed. Supports the policies and procedure process for Loma Linda University Medical Center (LLUMC) and participates in the development of department policies and other policies as requested. Manages timely review, revision, and distribution of policies. Drives between sites under Loma Linda University Health (LLUH) system as needed to accomplish responsibilities. Performs other duties as needed.

Education and Experience: Bachelor of Science Degree in Nursing or Health-related field required. Degree may be in progress at time of hire with reports provided to supervisor at designated intervals. Master of Science Degree in Nursing or related field, e.g., Public Health, Business, preferred. If candidate possesses Master of Science Degree, may have Associate's Degree in clinical health related field, e.g., Nursing, Respiratory Care. Minimum three years of participation in or experience in quality assessment and three years experience in an acute care hospital required.

Knowledge and Skills: Must have knowledge of state and federal healthcare regulations and accreditation, quality, patient safety, performance improvement processes and methodologies, data management and statistical analysis, medical staff structure and peer review process required. Must demonstrate solid clinical knowledge of clinical practice and standards. Must have highly developed oral and written communication skills in English and make public presentations. Advanced computer skills and proficiency in Windows environment, MS Word, Excel, PowerPoint, Internet Explorer, Outlook, advanced electronic medical record, data bases, spreadsheets, and graphics required. Must be consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction; think critically; use sound judgment based on factual information; set goals and work independently and efficiently with minimal supervision; perform basic math functions and statistical analysis of medical data and ensure integrity of data; demonstrate expert time management and prioritize fluctuating workload and to meet position demands; utilize problem-solving methodologies in a proactive and creative manner; recall information with accuracy; pay close attention to detail; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place; see adequately to read computer screens and written documents necessary to position. Exhibit professional behavior at all times and display personal qualities such as kindness, compassion, understanding, integrity, respect, sense of humor, discretion, and confidentiality.

Licensures and Certifications: Clinical License required in State of California, e.g. Registered Nurse, Respiratory Care. Certified Professional in Healthcare Quality (C PHQ) preferred. Six Sigma Green Belt certification preferred. Valid Driver's License and automobile insurance required at time of hire.