Clinical Quality, Safety & Performance Improvement Specialist (RN Preferred)

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Clinical Quality, Safety & Performance Improvement Specialist supports hospital-wide initiatives focused on quality improvement, patient safety, regulatory compliance, accreditation readiness, and patient experience. Partnering with nursing, medical staff, and operational leaders, this role uses data, performance improvement methodologies, and clinical expertise to improve patient outcomes, strengthen safety culture, enhance the patient experience, and ensure regulatory compliance.

Job Description

ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to)

Clinical Quality & Performance Improvement

• Partner with nursing, physician, and operational leaders to improve patient outcomes, quality measures, and clinical performance.
• Lead and support performance improvement initiatives using evidence-based methodologies such as PDSA, Lean, RCA, and FMEA.
• Analyze quality and clinical data to identify trends, risks, and opportunities for improvement.

Patient Safety & Risk Reduction

• Support the hospital's patient safety program through event review, investigation, and follow-up.
• Collaborate with frontline staff and leaders to implement corrective actions that reduce harm and improve safety outcomes.
• Promote a culture of safety and High Reliability Organization (HRO) principles.

Patient Experience & Regulatory Compliance

• Coordinate review and resolution of patient complaints and grievances while ensuring regulatory compliance.
• Support accreditation readiness activities, including audits, tracers, surveys, and compliance monitoring.
• Partner with clinical teams to improve patient experience, service recovery, and patient-centered care.

Data, Education & Collaboration

• Develop and present quality, safety, patient experience, and performance reports for leadership and committees.
• Provide education, coaching, and consultation to clinical teams regarding quality, safety, and regulatory requirements.
• Serve as a trusted resource to nursing and interdisciplinary teams on quality improvement and patient safety best practices.

QUALIFICATIONS

• State of Massachusetts Registered Nurse (RN) licensure (required)

Education

• Bachelor's degree in Nursing, Healthcare Administration, Public Health, Health Sciences, Quality Management, or related healthcare field required.
• Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or related field preferred.

Experience (preferred)

• Minimum of 1-3 years of experience in healthcare quality, patient safety, performance improvement, risk management, patient relations, regulatory compliance, accreditation, or related healthcare operations.
• Acute care hospital experience required.
• Experience supporting quality improvement, regulatory readiness, patient safety, or patient experience initiatives preferred.

PREFERRED CERTIFICATIONS

• Certified Professional in Healthcare Quality (CPHQ)
• Certified Professional in Patient Safety (CPPS)
• Lean, Six Sigma, or related Performance Improvement certification

OTHER REQUIREMENTS

• Knowledge of healthcare quality management principles and performance improvement methodologies.
• Working knowledge of patient safety, risk reduction, and quality improvement tools and techniques.
• Knowledge of CMS Conditions of Participation, The Joint Commission standards, Massachusetts Department of Public Health regulations, and other applicable regulatory requirements.
• Understand Quality Assessment and Performance Improvement (QAPI) principles and practices.
• Strong analytical, organizational, and problem-solving skills.
• Ability to interpret, analyze, and communicate complex performance and quality data.
• Excellent interpersonal, relationship-building, and collaboration skills.
• Strong written and verbal communication skills.
• Ability to facilitate multidisciplinary teams and lead improvement projects.
• Ability to manage multiple priorities and meet deadlines in a fast-paced healthcare environment.
• Proficiency in Microsoft Office applications, including Excel, Word, PowerPoint, and reporting tools.
• Ability to maintain confidentiality and exercise sound professional judgment.
• Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values.
• Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment

Physical & Environmental Requirements

This position requires frequent sitting, standing, walking, computer use, and participation in meetings throughout the organization. The incumbent must be able to travel throughout hospital departments and affiliated locations and participate in audits, surveys, investigations, and committee activities as needed.

Work is performed in a combination of office and healthcare environments with frequent interaction with physicians, staff, patients, families, hospital leaders, and external regulatory representatives. Occasional schedule flexibility may be required to support investigations, surveys, meetings, or organizational priorities.

Pay Range

$90,000.00 USD - $135,000.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.