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Full Time Day shift position working at Northwest Medical Center in Tucson, AZ

The RN Quality Management Lead is responsible for supporting the hospital’s performance improvement (PI) and regulatory compliance programs. This role involves analyzing performance data, identifying improvement opportunities, coordinating regulatory and accreditation activities, and ensuring compliance with healthcare regulations and standards. The Performance Improvement and Regulatory Specialist works closely with clinical, non-clinical and administrative teams to implement improvement initiatives and prepare for regulatory surveys and inspections.

Performance Improvement (PI) Responsibilities:

• Collect, analyze, and interpret performance data to identify trends and areas for improvement.

• Develop and implement performance improvement projects in collaboration with department leaders’ clinical, and non-clinical staff.

• Prepare and present data reports and dashboards to leadership to track PI progress and outcomes.

• In collaboration with the Director of Quality, monitor key performance indicators (KPIs) and provide recommendations for corrective actions.

• In collaboration with the Director of Quality, support departments in developing action plans to address performance gaps and improve patient outcomes.

• Develops, implements, and evaluates standards of care consistent with the Performance Improvement Program, including items requiring clinical nurse skills, such as, tracer tools for Suicide Risk Assessment, Restraints, Titration Care Plans, Fall Prevention, NPSG's, Critical Values, etc.

Regulatory Compliance Responsibilities:

• In collaboration with the Director of Quality, coordinate and oversee regulatory and accreditation activities to ensure the organization complies with federal, state, and local healthcare regulations.

• In collaboration with the Director of Quality, prepare for and facilitate Joint Commission, CMS, and state health department surveys and inspections.

• Conduct internal audits and gap analyses to identify areas of non-compliance.

• Collaborate with leaders to ensure their departments are in continual survey readiness, and to develop and implement corrective action plans to address compliance issues.

• Maintain up-to-date knowledge of regulatory and accreditation standards and communicate changes to relevant stakeholders.

• Serve as a liaison with regulatory agencies and accreditation bodies.

• Develop and deliver training sessions on regulatory and accreditation requirements.

• Reports survey activity and plan of correction updates as a result of a survey finding.

• Formats response to the regulatory agency and submits them timely.

• Updates the Joint Commission websites annually, and as needed when there are changes.

• Maintains open communication with the CHS regional Director of Regulatory Compliance regarding surveys and plans of correction.

• Updates Arizona Department of Health Licenses annually, and as needed.

• Performs other job duties as assigned.

Data Management and Reporting:

• Generate reports and presentations to communicate findings and recommendations to leadership.

• Ensure data accuracy and integrity in all reports and regulatory submissions.

Collaboration and Communication:

• Act as a resource for staff and leadership on performance improvement and regulatory issues.

• Facilitate multidisciplinary workgroups to address performance and compliance challenges.

• Promote a culture of continuous improvement and regulatory readiness across the organization.

Requirements and Qualifications:

Education:

• Associates degree in Nursing required. • Bachelor’s degree preferred.

Experience:

• Minimum of 1 year of experience in performance improvement, regulatory compliance, or healthcare quality management in the hospital acute care setting.

Skills and Competencies:

• Strong analytical skills with the ability to interpret and present complex data.

• Knowledge of healthcare regulations, accreditation standards, and performance improvement methodologies.

• Proficient in Google Workspace, and data visualization tools.

• Excellent communication and interpersonal skills.

• Ability to work collaboratively with clinical, non-clinical and administrative teams.

• Strong project management skills, preferred.

• Detail-oriented with a focus on accuracy and quality.

Northwest Medical Center (NMC) is a 287-bed hospital, with seventeen urgent care facilities, a freestanding emergency center, Northwest Transitions Inpatient Rehabilitation, Women's Center, and a large physician group, we offer you a variety of settings in which to work. Every location is dedicated to providing safe, quality patient care, but more than that is the commitment to employees. NMC provides a culture of teamwork, respect and appreciation for all staff, whether they care for patients directly or work in a support role. With employee appreciation celebrations throughout the year, opportunities for growth and the satisfaction that you are part of a hospital leading the way with accessible, convenient healthcare in Tucson, NMC is a great place to work. Accredited by The Joint Commission and is an equal opportunity employer: race, gender, disability and Veteran status, and VEVRAA Federal Contractor – priority referral Protected Veterans requested.

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.