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Quality Improvement Specialist RN (20 or 40hrs)

Department Description: Beth Israel Deaconess Hospital−Needham (BID−Needham) is a licensed 58-bed acute care community hospital. BID−Needham has served residents in Needham, Newton, Dedham, Dover, Medfield, Sherborn, Wellesley, Westwood and other surrounding communities for more than 100 years. The hospital has been recognized by several organizations for quality and safety, including the Gold Seal of Approval® from The Joint Commission and a first-place Accountable Care Compass Award from the Massachusetts Health & Hospital Association (MHA).
BID−Needham is part of Beth Israel Lahey Health, a new health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,000 physicians and 35,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.
BID Needham has had a direct affiliation with Beth Israel Deaconess Medical Center since 2000, facilitating the clinical integration of staff and resources in emergency medicine, hospital medicine (hospitalists), cardiology, radiology, orthopaedics, pathology, as well as many surgical services and oncology housed in the Beth Israel Deaconess Cancer Center and Surgical Pavilion.

Job Location: Needham, Massachusetts

Req ID: 41539BR

Job Summary: The Quality Improvement Specialist is a member of the Quality and Patient Safety team and is primarily responsible for management and data collection for external agencies such as CMS for core measures, American Stroke Association and Coverdell for the stroke program, third party payer projects including MA Health for pay for performance (P4P), and the Joint Commission for quality metrics. Works independently with above agencies. Works with clinical leaders on select improvement initiatives. Also participates in special projects as needed.

Essential Responsibilities:
  1. Abstracts data for CMS core measures, stroke program, third party payer projects related to pay for performance, and select DPH and other regulatory and improvement projects, Mass Health, Joint Commission.
  2. Trends data, compiles statistics, and runs reports weekly, monthly and quarterly for quality and patient safety, core measures, third party payer projects related to pay for performance, Joint Commission, and Mass Health.
  3. Acts as the Stroke Committee liaison responsible for data collection and data trending. Provides support for QI projects for the Stroke Committee and acts as the DPH/ASA/SCORE liaison. S/he is responsible for trending monthly and annual DPH standards per Stroke Certified Hospitals.
  4. Collaborates with clinical leaders on improvement initiatives. Provides data as indicated. Supports clinical leaders in identifying opportunities for improvement.
  5. Participates in relevant physician, nursing and community education via nursing orientation re pay for performance, JC core measures and DPH Standards; Actively participates in monthly Nursing Orientation re: Stroke Program, algorithms, guidelines; Annually presents, reviews with specific departments, and posts all Stroke related guidelines to the Portal.
  6. Updates Quality Team and clinical leaders regarding data trends and analyses from ongoing projects. Identifies opportunities for future studies and initiatives.
  7. Partners with IS to develop databases and storage links for information including confidentiality and integrity of data. Plays key role in the IS projects (such as CPOE, selection and validation of ECQM Measures annually). Ensures IS changes to support successful compliance with various metrics.
  8. Partners with Infection Control and Quality on projects related to patient safety and quality.
  9. Participates in Quality Improvement special projects as needed.
Required Qualifications:
  1. Associate's degree in Nursing required. Bachelor's degree in Nursing preferred.
  2. License Registered Nurse required.
  3. 3-5 years related work experience required in clinical care with at least one year of experience with quality and data analysis.
  4. Proficient in various external portals for data submission, abstraction and reporting.
  5. Strong analytic skills.
  6. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
  1. Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
  2. Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.
  3. Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.
  4. Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.
  5. Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.
  6. Knowledge: Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations.
  7. Team Work: Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.
  8. Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.

Physical Nature of the Job:
Light work: Exerting up to 20 pounds of force frequently to move objects. Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move through out the hospital campus
EOE Statement



As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. BILH requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement

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