Facility
Cape Fear Valley Medical Center
Location
Fayetteville, North Carolina
Department
Quality & Patient Safety
Job Family
Professional
Work Shift
Days (United States of America)
Summary
Responsible for ensuring that the health system meets quality standards and regulatory requirements. This involves analyzing clinical processes, implementing quality improvement initiatives, auditing records, training staff on best practices, and ensuring compliance with health and safety guidelines to improve patient care and integrity.
Major Job Functions:
The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below, and specific functions may change from time to time.
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Analyze clinical processes to identify areas for improvement and implementing quality initiatives to enhance patient care
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Audit records, conduct site audits, and verify compliance with regulatory guidelines and industry standards
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Ensure the accuracy and reliability of data by identifying and correcting discrepancies
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Train staff on best practices and ensure adherence to quality and safety protocols
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Develop quality metrics and prepare reports on quality performance
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Assist in monitoring quality improvement initiatives
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Investigate and monitor incident reports, patient care issues, patient complaints/grievances and provides follow up obtained from key stakeholders
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Assist with reviewing Patient Safety Events
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Demonstrate knowledge of current Joint Commission and CMS standards
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Assist with the tri-annual Joint Commission, CMS, and DHSR surveys
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Participate in departmental planning and development
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Other duties as assigned
Minimum Qualifications:
The following qualifications, or equivalent, are the minimum requirements necessary to perform the essential functions of this job.
Education and Formal Training
Work Experience
Knowledge, Skills, and Abilities
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Verbal and written communication
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Organizational skills
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Capacity to relate to people from various professional and nonprofessional backgrounds
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Understanding of quality planning, cost of quality, and importance of documentation
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Experience working with teams to include team building techniques and understanding team roles and responsibilities
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Ability to collect, aggregate and review data
Physical Requirements
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Ability to move throughout the Health System
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Visual acuity for reviewing data and reports and observing process flows
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Audiological acuity for monitoring group discussions and interactions
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Verbal ability is required to effectively express ideas and views to staff.
#CFVH-2025
Required Licenses and Certifications
Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity
