Healthcare Quality Specialist

POSITION SUMMARY

The Healthcare Quality Specialist supports Rocky Boy Health Center’s organization-wide Quality Assurance and Performance Improvement (QAPI), accreditation, patient safety, risk management, professional peer review, and infection prevention activities. Working under the direction of the Quality Director, this position monitors organizational performance, conducts audits and tracers, supports performance and process initiatives, assists with incident review and procedural development, and helps maintain continuous readiness for AAAHC accreditation and other applicable healthcare requirements.

As part of the Quality Department, the Healthcare Quality Specialist also supports RBHC’s Infection Prevention and Control Program through surveillance, monitoring, auditing, staff education, policy review, and implementation of infection prevention practices across the organization.

This position works collaboratively with clinical and operational departments to identify process and operational opportunities, implement changes, measure outcomes, and promote a culture of patient safety, accountability, and continuous improvement. This is an on-site position and is not eligible for remote work.

Quality Assurance & Performance Improvement

• Support RBHC’s organization-wide Quality Assurance and Performance Improvement (QAPI) program.
• Conduct clinical, operational, documentation, and compliance audits and tracers to evaluate adherence to organizational policies and applicable standards.
• Collect, analyze, and report quality and performance data to identify trends, risks, and opportunities for improvement.
• Assist departments with development and implementation of performance and process initiatives, including establishing measures, monitoring progress, and evaluating outcomes.
• Facilitate or participate in root cause analyses, procedural planning and follow-up monitoring.
• Develop dashboards, reports, and other tools to communicate quality performance to leadership, committees, and departments.
• Monitor the completion and effectiveness of process changes resulting from audits, incidents, complaints, accreditation findings, and other quality activities.

Accreditation & Regulatory Readiness

• Support continuous readiness for AAAHC accreditation and other applicable healthcare requirements.
• Conduct tracers, mock surveys, documentation reviews, and other accreditation readiness activities.
• Assist departments in interpreting standards, identifying operational gaps, and developing processes.
• Maintain documentation and evidence necessary to demonstrate compliance with accreditation standards.
• Review organizational policies, procedures, and practices for alignment with accreditation and regulatory requirements.

Patient Safety & Risk Management

• Monitor incidents, adverse events, near misses, and other patient safety concerns through Healthicity and other reporting mechanisms.
• Assist with the investigation, analysis, response, planning, and follow-up of reported events.
• Identify trends in patient safety and risk data and communicate significant findings to appropriate leadership and committees.
• Promote organizational reporting and a culture focused on learning, prevention, and operational excellence.

Infection Prevention & Control

• Support implementation and ongoing operation of RBHC’s Infection Prevention and Control Program.
• Conduct infection prevention surveillance, audits, tracers, and environmental rounds throughout clinical and support areas.
• Monitor adherence to infection prevention practices, including hand hygiene, standard precautions, transmission-based precautions, environmental cleaning, and other applicable protocols.
• Assist with investigation and follow-up of potential healthcare-associated…