- Quality Improvement Leadership
- Ensure hospital departments consistently adhere to established Quality Improvement (QI) principles, standards, and methodologies (e.g., PDSA, Lean, Six Sigma).
- Guide teams in defining problems, developing aims, mapping current workflows, and designing reliable future-state processes.
- Facilitate project charters, improvement team meetings, and barrierremoval discussions.
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- Data Interpretation & Run Chart Expertise
- Develop, maintain, and interpret run charts, control charts, and other QI data displays to help teams monitor performance and identify trends, shifts, or variations.
- Translate quantitative data into actionable insights to support informed decision-making.
- Assist leaders and frontline staff in understanding variation and applying rules for run chart analysis in daily management and improvement work.
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- Education, Coaching & Methodology Support
- Provide handson coaching and educate hospital teams on QI methods, including but not limited to PDSA testing, root cause analysis, workflow redesign, and reliability science.
- Support training sessions for new leaders, frontline staff, and physicians on core QI competencies.
- Serve as a subjectmatter expert in QI tools such as fishbone diagrams, 5 Whys, Pareto charts, standard work creation, and process mapping.
- Mentor departments on how to structure improvement projects, develop measures, and sustain gains.
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- Project Facilitation & Performance Monitoring
- Lead and support system and unit-level improvement initiatives focused on patient safety, clinical outcomes, operational efficiency, and regulatory measures.
- Ensure alignment of improvement work with organizational priorities, accreditation standards, and strategic goals.
- Track progress of assigned projects, assist with barrier identification, and guide corrective actions.
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- Stakeholder Engagement & Communication
- Collaborate with clinical leaders, physicians, nursing staff, and ancillary teams to promote a culture of continuous improvement.
- Communicate project outcomes, data insights, and improvement recommendations to leaders and committees in a clear, actionable format.
- Participate in and support hospital governance structures (Quality Council, Safety Committees, etc.).
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- Sustainment & Standardization
- Develop and maintain QI documentation, tools, templates, and training materials.
- Support teams in hardwiring successful interventions through standard operating procedures, monitoring plans, and performance dashboards.
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- Additional responsibilities as assigned
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