• Facilitates PA DOH occupancy process for new and existing services and complaint investigations for hospital outpatient services
• Serves as a coordinator for various hospital outpatient Regulatory Performance Improvement including but not limited to PA DOH and the Joint Commission.
• Participates and manages hospital outpatient infection prevention and control activities
• Understands and communicates Joint Commission, PA DOH and other governing body requirements which relate to Infection.
• Assists with the implementation and monitoring of the National Patient Safety Goals and other regulatory quality and safety requirements as assigned.
• Coordinates and participates in tracer activities throughout the hospital outpatient sites
• Assists Patient Safety officer in the management of incident reports and complaint investigations as assigned.
• Utilizes skill sets in process improvement, quality improvement, change management and team communication to develop and grow both current and new projects/programs.
• Manages project development, implementation and maintenance of system-wide programs.
• Assists medical and nursing directors in leading strategic development, tactical execution for solution strategies, and development of innovative road maps for care.
• Manages a clear and coherent strategy for identifying and capitalizing on revenue-generating opportunities with strategies, objectives and action plans based on a detailed understanding of the market, competition, customer needs, internal resources and capabilities.
• Establishes standard work to support department efforts for new and existing projects and program utilizing continuous quality improvement methodologies to identify clinical quality, process, and financial improvement opportunities within the department.
• Coordinates with all levels of leadership, physicians, other clinicians, nursing and ancillary staff in process improvement work, including but not limited to analyzing work flow, performing gap analyses, identifying process change and developing future workflows.
• Provides and/or coordinates education for department staff, including providers, on process improvement, quality and safety standards, practices, and policies.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.