- Associate's Degree
- Bachelor's Degree
- Project Management
- Microsoft Access
- Communication Skills
- Statistical Software
The Quality Specialist initiates and supports day-to-day functions, as well as strategic imperatives, that support infection prevention, quality, and performance improvement initiatives of Northern Light Continuing Care, Mars Hill and Northern Light AR Gould Hospital.
The Quality Specialist's scope of responsibly encompasses all settings of the organization. The coordinator will have intimate familiarity with the key elements of the Northern Light Health strategic plan, and a detailed understanding of the AR Gould Hospital Quality and Patient Safety plans. The Quality Specialist will skillfully use the techniques of system design, reengineering, project management, quality improvement, outcomes measurement, and basic statistical analyses to advance goals and objectives of the plans. The position will also serve as the Infection Control resource for Northern Light Continuing Care site in Mars Hill.
Licenses or Certifications: Certified Professional of Healthcare Quality (CPHQ), LEAN, or Six Sigma preferred
Education Requirements: Associate's degree in health sciences, public health, healthcare administration, medical assisting, or related field. Bachelor's degree preferred.
Work Experience & Skills: A minimum of two (2) years working experience in quality and/or performance improvement or project management; healthcare experience required and knowledge of CMS and Joint Commission quality/performance measures.
Software and technology: MS products including Excel, MS Access, PowerPoint, and statistical software.
Ability to foster a cooperative work environment.
Excellent problem solving and communication skills.
Ability to perform statistical analysis and understand the appropriate applications of interpretive statistics, display of data using graphical techniques such as scatter plots, histograms, bar charts, trend lines, etc. preferred.
Team development and facilitation techniques applied to quality improvement or project teams to achieve their highest potential.
Organization and planning, managing multiple demands, and achieving results.
Exceptional verbal, written, and presentation skills.
Age Specific Performance
Demonstrates knowledge, skills, and abilities necessary to provide care to the age groups served.
1. Knowledge of normal growth and development.
2. Ability to assess, provides, and interprets age-related data.
3. Ability to perform age-specific treatments.
4. Ability to interpret age-specific response to treatment.
5. Ability to use age-appropriate communication.
6. Knowledge of age-specific community resources.
Job Specific Performance
1. Surveillance, Prevention and Control Program Development, Coordination and Direction:
Under the leadership of the Manager of Infection Prevention and Quality, and in collaboration with the Infection Control Committee, designs and implements a surveillance plan and program objectives.
Systematically collects data for the purpose of identifying and tracking high risk, high volume healthcare-associated infections and sources of infection.
Makes recommendations for program and policy development for the prevention and control of infection and exposure to bloodborne pathogens among patients, visitors, staff, and all associates.
Assists in the implementation of programs in order to meet compliance with State, Joint Commission, OSHA, and CDC guidelines and recommendations related to Infection Control. This includes assistance with the facilities "mock survey" procedures.
Actively participates in and leads implementation of new initiatives.
Promotes, implements and monitors an effective hand hygiene program that complies with the Joint Commission's Hand Hygiene National Patient Safety Goal and CDC guidelines.
Adheres to State and Federal mandates, investigates, manages, and reports outbreaks of infection. Collaborates with Maine CDC as necessary.
Assists with the review and revision of infection control policies/procedures to meet changing practices and standards in all organizational settings including hospital, outpatient dialysis, medical office practice, and nursing facility.
Evaluates isolation techniques and assists with placement of patients as needed.
Provides necessary infection control education for all employees when necessary.
2. Patient Safety Promotion:
Develops patient safety strategies in partnership with system patient safety leaders, to be instituted across the organization. This may require partnership with the Senior Physician Executive, AVP of Nursing, or other leaders who can support and authorize new safety protocols.
Reinforces a culture of patient safety through encouraging the reporting of near misses and patient safety events, and through the facilitation of the culture of patient safety survey and its associated action plans.
3. Quality Monitoring and Improvement:
Actively participates in data collection and analysis of assigned projects
Identifies trends from analyses.
Actively participates on system and local improvement teams
Supports the use of quality improvement models such as CUSP, and RCA2 to assist in the exploration of issues that may arise.
Participates as needed in the staff development activities to support quality improvement activities.
Responsible for the assistance with facilitation of mock surveys at the facility, as well as any follow up education and action plans as appropriate.
In collaboration with providers and staff, assesses, develops and implements programs to meet the needs of all staff. This can include: hospital orientation for new employees; and specific train-the-trainer programs in aspects of infection control such as HIV counseling, or others as needed.
Promotes, provides education, and monitors infection control and patient safety practices on an ongoing basis
Performs rounds on all patient care areas at Northern Light Continuing Care for case findings and teaching purposes. Frequency based on prioritization of risk factors and identified trends/patterns.
Participates in the development and review of standards of care, policies and procedures relevant to infection control and quality for Northern Light Continuing Care
Serves as a resource in infection and exposure-related incidents and infectious and contagious disease related diagnosis.
Maintains a collaborative relationship with the organizational safety officer and meets regularly to focus on shared responsibility for the design and implementation of interventions to decrease employee exposures/infections, improve quality and employee satisfaction
Participates in the development of performance improvement metrics and projects related to infection control and quality.
Provides direct patient consultation for complex infection control situations.
Consults with health care providers concerning the delivery of care, which enhances desired patient care outcomes.
6. Outcome Evaluation:
Works in conjunction with other members of the healthcare team works to evaluate and modify the plan of care based on achievement of patient outcomes.
Collaborates with other members of the health care team to modify the plan of care as needed.
Identifies and communicates potential quality concerns to the Manager of Infection Prevention and Quality or other colleagues at Northern Light Continuing Care.
7. Professional Practice/Leadership:
o Maintains patient confidentiality at all times.
o Represents the organization in a positive and professional manner in the community.
o Maintains regulatory requirements, including Joint Commission, Federal, and State laws and regulations.
o Complies with all organizational policies regarding Northern Light Health's Code of Conduct and ethical business practices.
o Maintains and abides by ethical standards put forth by the facility and all licensing boards and professional organizations to which the employee is responsible.
8. Performs additional duties as required or assigned.