Quality Improvement Specialist I - Quality Outcomes - Full Time

Position Summary

The Quality Performance Improvement Specialist I (QPIS I) oversees and facilitates quality improvement and patient safety activities while serving as a hands-on improvement leader. This role supports the administration of organizational quality programs and quality-of-care improvements through facilitation, advising, advocacy, and the coordination of data collection/aggregation and actionable analysis.

Essential Functions / Job Responsibilities

• Lead and facilitate clinical and operational quality improvement initiatives aligned with organizational and strategic objectives, using improvement methodology to achieve intended outcomes.
• Maintain current best-practice understanding in quality and patient safety; assess gaps between current state and best practice; recommend process changes that impact quality and safety.
• Routinely evaluate indicators and report to stakeholders to ensure continuous improvement; develop and/or direct ongoing performance improvement initiatives and standardize practices.
• Collect, compile, coordinate, and aggregate data to support quality programs; mine new/existing systems and processes for actionable data and act where appropriate.
• Perform retrospective chart audits and medical record analysis for key quality metrics and identify improvement opportunities in clinical and/or documentation processes.
• Analyze performance metrics to identify trends or root causes; prepare reports and formal presentations of results and present to appropriate committee(s).
• Maintain thorough understanding of regulatory, accreditation, quality reporting, and national quality standards/strategies; interpret quality standards and stay current with evolving requirements.
• Participate in regulatory and survey activities including Joint Commission and CMS surveys; provide primary support and lead Leapfrog action planning and survey completion.
• Facilitate and lead clinical improvement teams to identify, plan, implement, and sustain change using relevant quality tools and timelines; apply PDSA and other tools appropriately to improve care and services.
• Coordinate and/or facilitate quality governance committees within the governance structure (agenda support, minutes/records as applicable).
• Collaborate with other departments (e.g., patient safety, informatics, clinical systems, case management, regulatory compliance, population health, value-based reimbursement, policy management, clinical service departments and leaders) to develop and implement improvement projects supporting quality initiatives and concerns.
• Respond to requests for explanation from payors related to quality-of-care letters/clinical concerns as appropriate.
• Provide direct supervision to assigned quality staff as applicable (assign work, review work, performance management/evaluations) and promote an engaged, healthy work environment emphasizing growth and development.

Education, Licensure & Certification

• Bachelor’s degree required (e.g., Project Management, Process/Performance Improvement, Health Implementation, Data Analytics, Systems Science, or related healthcare field).
• Master’s degree preferred.
• Certified Professional in Healthcare Quality (CPHQ) within 3 years.
• Licensure/certification in a healthcare-related field may be required (e.g., RN or other licensure/certification as applicable).

Experience, Knowledge, Skills & Abilities

• Demonstrated project management, analytical, organizational, audit, computer, communication, and customer service skills.
• Quality improvement experience in healthcare and demonstrated execution of quality improvement projects addressing quality-of-care concerns.
• Clinical knowledge/experience may be required depending on assignment (source references inpatient acute care experience).
• Ability to facilitate multi-disciplinary teams, produce written/verbal reports, and lead change initiatives aligned with organizational mission/values.

Other Duties:

Performs other duties as assigned and within scope of job function. In addition to the essential functions listed above, the following duties are an expectation of this role:

1.    Travel for this position is sometimes required.

2.    Participation in community and employee engagement activities is required.

3.    Actively participates to move the team toward the completion of goals.

4.   Always exhibits a high degree of professionalism and decorum consistent with Guthrie values

5.    Makes procedural or process suggestions for achieving team goals or performing team functions; provides necessary resources or helps to remove obstacles to help the team accomplish its goals.

6.    Listens to and fully involves others in team decisions and actions; values and uses individual's differences and talents. ‐ Shares important or relevant information with the team.

7.     Builds a positive team by helping and support to co‐workers, patients, vendors, and partners.

8.     Works actively to resolve conflicts.

9.   Restates the opinions of others to clarify understanding.

10.   Presents information effectively in a variety of settings: one‐on‐one, small and large groups, with peers, direct reports, and superiors.

11.    Listens actively and is open to feedback. Provides fair and constructive feedback to others.

12.    Keeps team members and customers adequately informed.

13.     Displays original thinking and creativity to generate suggestions for improving efficiency and effectiveness.

14.    Meets challenges with resourcefulness and solution orientation.

15.     Demonstrates persistence and overcomes obstacles.

16.     Tries new approaches when problem solving, seeking ideas or suggestions from others as appropriate.

It is understood that this description is not intended to be all‐inclusive and that other duties may be assigned as necessary in the performance of this position.

Updated: 6-2-26

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