Healthcare Quality Analyst; ONSITE

At Surgical Institute of Reading (SIR), we build relationships that create better care. We partner with physicians and healthcare systems to provide first-class surgical solutions. Our commitment to clinical excellence and operational efficiency allows us to deliver exceptional surgical services that improve patient outcomes. SIR is proud of our inclusive culture—we embrace diversity and value the contributions of every individual. A diverse workforce, combined with an inclusive environment, strengthens our ability to serve diverse patient and physician populations.

The Quality Analyst supports the organization's Quality Assessment and Performance Improvement (QAPI) program through the collection, validation, analysis, and reporting of quality, patient safety, patient experience, infection prevention, and regulatory compliance data. This position assists facility leadership in monitoring performance indicators, identifying trends, preparing reports, and supporting performance improvement initiatives. The Quality Analyst works collaboratively with leaders, physicians, and staff to promote a culture of quality, patient safety, continuous improvement, and survey readiness.

The following description of the job responsibilities and performance expectations are intended to reflect the primary responsibilities of the job but are not intended to describe all duties. Other responsibilities may be assigned from time to time.

• Collects, validates, enters, maintains, and analyzes quality, patient safety, infection prevention, patient experience, and operational performance data.
• Generates routine and ad hoc reports, dashboards, scorecards, and performance summaries for leadership, committees, and regulatory reporting needs.
• Assists with monitoring organizational quality indicators and performance improvement initiatives.
• Identifies trends, variances, opportunities for improvement, and potential compliance concerns through data analysis and reporting.
• Supports preparation of materials for Quality/Performance Improvement Committee meetings and other quality-related committees.
• Maintains databases, trackers, and documentation required for quality, risk, accreditation, and regulatory activities.
• Assists with collection and submission of required state, federal, CMS, accreditation, and corporate quality reporting measures.
• Supports incident reporting processes through data review, tracking, trending, and follow-up documentation.
• Assists with root cause analyses, failure mode and effects analyses (FMEA), corrective action plans, and performance improvement projects.
• Performs chart audits and data abstraction as required for quality monitoring, accreditation standards, and regulatory compliance.
• Monitors compliance with facility policies, quality standards, and performance metrics.
• Supports patient experience initiatives through collection, analysis, and reporting of patient satisfaction data and trends.
• Tracks action plans resulting from quality reviews, audits, committee recommendations, and performance improvement activities.
• Assists with accreditation readiness activities and participates in state, federal, and accrediting agency surveys.
• Maintains knowledge of applicable regulatory requirements, quality standards, and accreditation expectations.
• Collaborates with department leaders to provide data support for performance improvement activities.
• Assists with development of educational materials, reports, presentations, and communications related to quality initiatives.
• Maintains confidentiality of quality, peer review, patient, employee, and organizational information in accordance with applicable regulations and policies.
• Demonstrates commitment to continuous quality improvement and patient safety principles.

• Bachelor's degree in healthcare administration, nursing, public health, business, data analytics, or related field preferred.
• Associate degree with relevant healthcare quality experience may be considered.
• Minimum one to three years of healthcare, quality improvement, regulatory, accreditation, data analytics, or clinical experience preferred.
• Knowledge of healthcare quality improvement principles, regulatory requirements, and accreditation standards preferred.
• Experience with data management,…