Quality Project Coordinator

Job Description Summary

Responsible for supporting the planning, implementation, and monitoring of quality improvement projects. This role involves coordinating various quality initiatives, managing project timelines, and ensuring compliance with healthcare standards and regulations while working closely with clinical and administrative teams to enhance patient care quality, safety, and operational efficiency.

Functions as the hospital's Patient Family Relations (PFR) lead, responding to patient and family complaints and grievances in accordance with regulations.

Does this position require Patient Care? No

• Assists in the planning and execution of quality improvement projects, ensuring alignment with organizational goals and objectives. Coordinates project activities, including scheduling meetings, preparing agendas, and maintaining project documentation.
• Monitors project progress against timelines and deliverables, identifying and addressing any issues or delays.
• Collects, organizes, and analyzes data related to quality measures, patient outcomes, and performance metrics. Supports the development of reports, dashboards, and presentations to communicate project progress and results to stakeholders.
• Serves as a liaison between project teams, clinical staff, and leadership to facilitate communication and ensure project alignment with departmental needs.
• Ensures that quality projects adhere to relevant regulatory requirements and accreditation standards.
• Assists in the preparation of regulatory surveys and audits by compiling necessary documentation and evidence of compliance. Stays informed about changes in healthcare regulations and standards that may impact quality projects.
• Actively participates in on‑site unit‑based tracer activities and unit follow‑up visits to ensure hospital is in compliance with all applicable regulatory standards.
• Tracks the effectiveness of implemented changes and makes recommendations for further improvements.
• Coordinates hospital's Policy Leadership Committee and is lead for Ellucid Policy Management system.
• Works with patients, families and hospital leadership in acknowledging and responding to patient family grievances and complaints in a compassionate, supportive and timely manner.
• Provides assistance to patients and families with needs or concerns regarding patient rights and responsibilities, and responds to patient complaints or concerns in accordance with federal, state, and local regulatory standards and accreditation requirements for patient complaints and grievances.
• Prepares formal correspondence and documentation (both patient‑facing and internal), such as letters, messages, and reports, with efficiency and accuracy.
• Fosters teamwork and partnerships between hospital staff, physicians, and department leaders, Quality, Risk, and Compliance to ensure responses are patient/family centric.
• Provides telephone coverage and in‑person support of patient and family relations for patients' and loved ones' needs, concerns, or complaints. Conducts rounds with patients, families, and visitors to obtain preemptive feedback regarding the inpatient hospital experience, when appropriate and aligned with hospital safety policies.
• Functions as the civil rights coordinator in receiving and coordinating follow‑ups on any civil rights or health equity complaints.
• Documents information regarding patient and/or staff concerns and requests in a confidential department database and disseminates data to appropriate leadership staff for quality assurance purposes.
• Utilizes data management system to meet regulatory requirements for all federal, state, and local regulatory standards and accreditation requirements regarding complaint management and resolution process.
• Maintains organized and accurate project documentation, including plans, timelines, meeting minutes, and action items.
• Because this role is in an active change management environment, the individual will need to demonstrate flexibility and open‑mindedness as the contours of this position will actively evolve over time.
• All other duties as assigned and requested.

Associates or Bachelor's Degree required.

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