Sr Quality & Patient Advisor, Accreditation/Regulatory

Discover Vanderbilt University Medical Center:

Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded and your abilities challenged. It is a place where your diversity — of culture, thinking, learning and leading — is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday.  Vanderbilt's  mission is to advance health and wellness through preeminent programs in patient care, education, and research.

• The Department of Quality, Safety and Risk Prevention (QSRP) equips and empowers VUMC faculty and staff to offer care that is safe, timely, effective, efficient, and patient-centered. As a member of QSRP, this position is responsible for the engagement of Vanderbilt Health System faculty and employees to ensure compliance with all applicable federal and state regulations.
• Acts as a performance improvement engineer and patient safety manager for quality and patient safety activities within the Accreditation and Standards team of QSRP.
• Provide project mgmt facilitation, education and data analysis for improvement of organizational or departmental systems/processes. Assist with coordination, aggregation, analysis, and translation of info for use by leadership and improvement teams.
•  Provide leadership and coordination of major projects and initiatives.
• Provide research and analysis of Regulatory requirements, coordinates and facilitates analysis to identify process/system flaws and assist in development of planning for process redesign.
• Coach and mentor staff and mgmt in quality improvement, process management, and event analysis.  Mentor internal staff to expand knowledge and expertise.

• Documents and evaluates project outcomes to facilitate organizational memory and knowledge transfer including:
• User challenges, needs, interests and concerns
• Policy and procedure issues
• Organizational changes
• Useful communications, analysis, presentation techniques
• Best practices and lessons learned
• Under minimal supervision, coordinates and oversees the evaluation and planning phases of projects
• Organizes team resources, including steering committees, projects teams and work groups as needed
• Research evidenced based care
• Develops high level project plan and achieves buy-in on task responsibilities and timelines from the appropriate team members
• Defines communications, issue management and scope management strategy and achieves approval from the appropriate team members
• Identifies, evaluates, documents and manages project issues and risks and escalates, as appropriate, to achieve timely resolution
• Assists in defining project objectives and success metrics
• Creates and communicates appropriate documentation, including project overview, scope, team structure, status reports, issue management reports, change control reports, and meeting notes, as directed, in a timely manner
• Under minimal supervision, serves as a project leader to ensure timely completion of tasks in line with project and organizational objectives
• Manages and communicates project status to team members and executive staff.
• Provides documentation to communicate project status to team members and executive staff, as directed
• Identifies and documents project issues and risks and escalates, as appropriate, to achieve timely resolution
• Ensures compliance with regulatory agencies including meeting deadlines, when applicable
• Assists and/or develops measures to quantify process or quality improvements
• Coordinates the introduction and incorporation of quantitative or qualitative evaluation measures into project requests and evaluations
• Assists department managers or other quality improvement teams in identifying, developing and monitoring outcomes
• Assists in coordinating planning for obtaining data in evaluation measures.
• Outlines and conveys responsibility for achieving proposed goals to appropriate persons whiles supporting and suggesting measures that quantify benefits.
• Actively consults with management and/or QI teams to ensure goals are achieved
• Obtains data to evaluate project at completion and formally closes project.
• Participates in improving organizational performance through improvement activities and process engineering
• Collects and analyzes data
• Provides input to departmental discussions based on data, best practice research and benchmarking
• Coordinate and facilitate event analysis process
• In coordination with Risk Management and organizational leadership, coordinate event analysis process (arrange meeting logistics)
• Assist in the research and analysis of event
• Assist in the development of action planning with all levels of organizational leadership
• Coaches and mentors staff and management and mentoring of QC's in areas such as quality improvement and process management.
• Provides education and consultation to teams through in-service, orientation, individual and/or group sessions
• Maintains current knowledge of process improvement literature and resources, and stays abreast of TJC and other regulatory agency standards. Attends related conferences, seminars and topic-specific process improvement meetings
• Department Administration
• Supervise, manage, or participate in departmental assignments. Handle planning, selection, logistics
• Actively mentor other quality improvement consultants to expand their knowledge and expertise

• Master's Degree (or equivalent experience) and 10+ years hospital/healthcare experience; 3-5 years experience in process improvement required at Vanderbilt

• Registered Nurse

VUMC Recent Accomplishments

Because we are committed to providing the best in patient care, education and research, we are proud of our recent accomplishments:

• US News & World Report:   #1 Hospital in Tennessee, #1 Health Care Provider in Nashville, #1 Audiology ( Bill Wilkerson Center ), 12 adult and 10 pediatric clinical specialties ranked among the nation's best, #15 Education and Training
• Truven Health Analytics:   among the top 50 cardiovascular hospitals in the U.S.
• Becker's Hospital Review:   one of the "100 Greatest Hospitals in America"
• The Leapfrog Group:   grade "A" in Hospital Safety Score
• National Institutes of Health:   among the top 10 grant awardees for medical research in the US
• Magnet Recognition Program:   Vanderbilt nurses are the only group honored in Tennessee
• Nashville Business Journal:   Middle Tennessee's healthiest employer
• American Hospital Association:   among the 100 "Most Wired" medical systems in the US