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Job Title

• Safety, Quality and Patient Experience
• Sepsis

Location

Mayfield Hts

Facility

Hillcrest Hospital

Department

Office of SQPE East-Clinical and Operational Improvement

Job Code

T97901

Shift

Days

Schedule

8:00am-5:00pm

Job Summary

Job Details

Serving the needs of Garfield Heights and the Southeast communities of Cuyahoga County, Marymount Hospital is an acute care, faith-based hospital. Here, caregivers are guided by the Christian values of service, compassion, dignity and respect and live by the mission of providing world-class healthcare. As a part of our team, you will build a rewarding, lifelong career in a diverse and welcoming environment.

The Safety, Quality and Patient Experience (SQPE) – Sepsis role is dedicated to improving sepsis outcomes and reducing mortality through enterprise-wide quality and safety initiatives. This position ensures adherence to evidence-based sepsis bundles, keeps clinical staff informed on best practices, and leads chart audits, documentation review, and education efforts. The role collaborates closely with physicians and nursing teams across the ICU, Emergency Department, and Med/Surg units, delivering presentations and driving engagement. Operating within a matrixed environment, the caregiver partners with leadership and sepsis experts to identify trends, close performance gaps, and implement targeted improvements aligned with organizational goals and OKRs. Ideal candidates bring an RN background in acute care (Med/Surg or ED), at least five years of experience, strong analytical and communication skills, and a proactive, self-starter mindset.

A caregiver in this position will work 8: 00am to 5:00pm, Monday through Friday.

A caregiver who excels in this role will:

• Direct safety, quality, and patient experience work within assigned scope of responsibility.

• Coordinate and implement improvement initiatives using the Cleveland Clinic Improvement Model.

• Coordinate with cross functional stakeholders to ensure compliance with all standards and favorable performance on safety, quality, utilization, and experience metrics.

• Participate in engraining the safety, quality, and experience requirements as outlined by regulatory and accreditation bodies.

• Manage performance improvement regarding SQPE with all departments providing patient care.

• Understand and implement elements of performance as outlined by regulations, bylaws, and rules and regulations established by the medical staff.

• Act as the primary resource for staff to facilitate overall operations of programs.

• Develop meaningful quality assurance and improvement activities with clinical and operations leadership to establish when a deviation in standard practice has occurred.

• Act as a consultant in educating and evaluating clinical and support department staff regarding quality management regulations and standards of care.

• Support medical staff quality assurance activities such as peer review, ongoing professional practice evaluation, and focused professional practice evaluation.

• Incorporate regulatory and accreditation standards into improvement activities around SQPE.

• Collaborate on development of required plans such as the performance improvement plan, safety plan, infection control plan, and others as required by governance.

• Incorporate enterprise priorities and regulatory requirements and benchmarks ensuring alignment to one standard of care across locations.

• Drive continuous improvement activity around quality, safety and patient experience priorities and coordinate improvement projects.

• Facilitate dashboard reviews, data analysis and decision-making from data.

• Manage stakeholder relationships, project risks and project changes.

• Lead projects and facilitate multidisciplinary teams leveraging advanced continuous improvement and project management tools.

• Coach smaller improvement teams to success with their quality improvement projects at the local level.

• Report on medical errors/near misses and corrective actions taken.

• Oversee the management and use of medical error information.

• Apply the Cleveland Clinic cause analysis process to identify key factors that lead to failures in SQPE.

Minimum qualifications for the ideal future caregiver include:

• Bachelor’s Degree in Nursing, Healthcare Administration, Business, Engineering or a related field OR in lieu of Bachelor’s degree, five (5) years of Safety, Quality, Patient Experience, Accreditation, Risk, Clinical, or Continuous Improvement experience may suffice.
• Minimum one (1) year of related experience with Safety, Quality, Patient Experience, Accreditation, Risk, Clinical, or Continuous Improvement.
• Familiarity with basic statistical analysis, continuous improvement tools and change management technique

Preferred qualifications for the ideal future caregiver include:

• Master’s Degree

• Current licensure as a Registered Nurse (RN)

• Certified Patient Safety Professional (CPPS) OR Certified Professional in Healthcare Quality (CPHQ)

• Healthcare Accreditation Certification Program (HACP), Certified Joint Commission Professional (CJCP), Process Improvement Certification, Certification in Infection Control (CIC) or Certified Patient Experience Professional (CPXP)

• Clinical experience

• Experience working with Joint Commission, HFAP or CMS surveys and processes, preferably in a leadership/coordinator role

Physical Requirements:

• Ability to communicate and exchange accurate information.

• Ability to perform work in a stationary position for extended periods.

• Ability to work with physical records or operate a computer or other office equipment.

• In some locations, ability to travel throughout the hospital system.

• In some locations the ability to move up to 25 lbs.

Personal Protective Equipment:

• Follow standard precautions using personal protective equipment as required.

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster.

Cleveland Clinic is pleased to be an equal employment opportunity employer.