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Waverly Health Center Patient Safety & Quality Specialist 1.0 FTE in Waverly, Iowa


FTE: 1.0, 1st shift, Monday-Friday daytime hours. No weekends, no holidays.


Utilizes data, evidence-based practice, and quality improvement tools to coordinate and lead Waverly Health Center’s (WHC’s) improvement and patient safety efforts.


  • Improvement Expert:

  • Is a content expert, and remains current and well-informed on various process improvement tools, including but not limited to those associated with Lean, continuous improvement, sustainability, Joint Commission (JC), Root Cause Analysis, etc.

  • Accepts the responsibility for defining and consistent­ly pursuing own continuing education requirements.

  • Remain current and well-informed on patient safety practices in hospital and clinic settings.

  • Improvement Identification:

  • Proactively identifies opportunities for improvement and patient safety within the organization through various methods including but not limited to use of relevant data.

  • Identifies, extracts and analyzes data, formulating recommendations for process improvement.

  • Effectively prioritizes improvement activities to create patient safety in all patient care areas of the hospital and clinics.

  • Actively reviews patient surveys/feedback to identify opportunities for improvement and ensure a positive patient experience.

  • Serves as a regulatory expert for the hospitals and clinics and completes regulatory education with staff as appropriate. Rounds in departments to identify regulatory opportunities for improvement.

  • Improvement Leader:

  • Effectively works with committees, departments, and staff (including practitioners) to lead and facilitate improvement and patient safety activities. Maintains accountability in this regard of self, peers and staff.

  • Develops and conducts employee education regarding general performance improvement tools.

  • Coordinates and facilitates Patient Safety Committee and data sharing including culture of safety.

  • Attends department huddles and provides input towards current process improvement metrics.

  • Improvement Implementation:

  • Effectively works with all areas including, Non-Clinical, Clinical and Practitioners, to implement improvements within the organization that result in long-term, sustained changes:

  • Utilizes relevant data to determine priority of improvement efforts.

  • Drives improvements through proactive collaboration with staff.

  • Conducts root cause analyses on events or metrics with clear outcomes and process improvement at completion.

  • Works with each department as-needed to standardize processes using evidence-based standard-of-work.

  • Works with Information Systems as needed to optimize electronic methods of work.

  • Actively participates on appropriate committees to share information and implement positive change/process improvements.

  • Data Knowledge and Reporting:

  • Remains current and generally informed on applicable state/federal/accreditation regulations on clinical quality data reporting requirements, including but not limited to Centers for Medicare & Medicaid Services (CMS), Joint Commission (JC), Iowa Healthcare Collaborative (IHC), etc.

  • Remains current on, and maintains detailed knowledge of, the facility’s publicly reported quality data, including trends and benchmarking variations, in order to identify improvement efforts.

  • Identifies and tracks indicators to effectively measure improvement and patient safety efforts.

  • Becomes a content expert for measures associated with improvement and patient safety efforts.

  • Maintains access to platforms needed to submit data to local/state/national organizations as directed based on facility participation.

  • Submits data within defined timeframes based on platform deadlines.

  • Systems Utilization for Data Analysis:

  • Maintains a high-working knowledge of Excel/other programs in order to effectively analyze data and identify improvement opportunities.

  • Acts as a system administrator for the variance reporting system to maintain user rules, form updates/development, and optimize staff understanding/usage. Ensures variances have appropriate follow up in a timely manner and close them when complete.

  • Effectively shares data with staff, providers, and leadership.

  • Team Participation:

  • Maintains active membership in committees/taskforces and departmental projects.

  • Represents WHC by participating as directed on local/state/national projects/initiatives as deemed relevant for WHC.


  • Education, Experience, and Training

  • Must be a graduate of an accredited school of nursing and currently licensed to practice as a Registered Nurse in Iowa. Bachelor’s degree preferred.

  • Minimum 2 years of rural health clinic, emergency department or critical care nursing experience.

  • CPHQ preferred.

  • Prior work with quality improvement tools.

  • General knowledge of process improvement tools required. This includes but is not limited to Lean, continuous improvement, sustainability, International Organization for Standardization (ISO), etc. Certification in Lean Six Sigma Black Belt is a plus, but not required.

  • A basic knowledge of Centers for Medicare and Medicaid Services (CMS) and Joint Commission (JC) standards is preferred.

  • Must possess ability to learn and navigate computer systems including the online training modules, the employee timesheet and the performance appraisal system.

  • Must have ability to adapt to and navigate various databases and computer systems.

  • Must have skills and ability to identify opportunities and oversee the improvement process to implement lasting changes.

  • Must be able to effectively communicate with hospital staff.

  • Must have attention-to-detail in all aspects of work.

  • Must be able to read, speak, and write fluent English.

  • Physical Requirements

  • Sitting – Approximately 60% of shift.

  • Standing – Occasional.

  • Walking – Occasional.

  • Lifting – Not a requirement.

  • Twisting – Not a requirement.

  • Bending – Occasional.

  • Squat/Kneel – Occasional.


  • May come in contact with hazardous chemicals or treatment modalities.

  • The possibility exists of exposure to communicable disease due to working in a healthcare environment.

  • Involvement in patient care may result in unavoidable work-related illnesses.


    This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. A review of this description has excluded the marginal functions of the position that are incidental to the performance of fundamental job duties. All duties and responsibilities are essential job functions. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by his/her manager.

    Requirements are representative of the minimum levels of knowledge, skills, and/or abilities. To perform this job successfully, the employee will possess the abilities or aptitudes to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health and safety of themselves or other employees. All requirements are subject to possible modification to reasonably accommodate individuals with disabilities.

    This document does not create an employment contract, implied or otherwise, other than an "at will" employment relationship with the Waverly Health Center.