St. Johns Medical Center
  • Quality
  • Jackson, WY, USA
  • Competitive
  • Full Time

The primary function of this position is to work with clinicians and administrators within the Medical Center to implement clinical system and process improvements that will improve patient outcomes, enhance clinical performance, and produce necessary information to maintain accreditation and CMS performance standards. 


  • Participates in the collection and analysis of clinical outcomes data inn order to develop clinical process improvement initiatives. Identifies and reports trends identified through monitoring the Quality Improvement and develops actions to improve.
  • Routinely assesses the integrity of Quality data and information across the organization and initiates processes to resolve data issues. Ensures regulatory required QA (e.g. Refrigerator temperatures) is being collected and reported.
  • Maintains current knowledge of the DNV-GL, State of Wyoming and CMS standards and assists the unit/organization in maintaining compliance with all applicable standards. Uses appropriate tools and processes for quality management (including but not limited to failure modes and effects analysis) and participates in the education of staff regarding those methods.
  • Drives improvements in care quality, & operational efficiency by identifying, planning & facilitating continuous improvement activities together with staff leadership & physicians. Lead and/or participate in performance improvement teams. Provides quality & process improvement expertise & facilitates development of standardized approaches to creating performance improvement plans, defining appropriate tools, methodologies and metrics, analyzing & interpreting data, managing change & facilitating improvement teams.
  • Conducts FMEAs or other group analysis tools  as assigned, including the development, implementation & evaluation of the action plan. Improves care delivery systems, & system reliability through identification of areas that are high risk & problem prone. Acts as a resource to staff, managers, & medical staff to facilitate effective PI. Understands and is able to clearly articulate PI plan, process & tools. Assists staff & medical staff in application of appropriate PI tools to current projects, processes, & the PI Plan.
  • Assists department/committees with monitoring, evaluation, and PI initiatives. Provides guidance and feedback to Quality Action Team (QAT) leaders and facilitators for group dynamics, skill development, and use of various PI methods and tools. Mentors individuals and teams in improvement methods, project management, change management, group dynamics and planning methods. Educates all staff and medical staff on the performance improvement model and tools.
  • Acts as a liaison between Quality Management and Patient Safety, physicians and hospital staff. Develops and performs physician and clinical education material and tools on evidence-based practices surrounding quality initiative/project, core measures and public reportable metrics. Identifies and removes barriers to project success or escalates to leadership when appropriate.
  • Uses appropriate tools and processes for quality management (including but not limited to failure modes and effects analysis) and participates in the education of staff regarding these methods.

REQUIRED QUALIFICATIONS: B.S. in a health related field, preferably nursing. Experienced in process improvement methodologies, e.g., FMEA, Statistical Process Control or Lean methodology. Working knowledge of DNV-GL standards. Excellent oral, and interpersonal written communication skills, poise in teaching, facilitating and consulting. Strong organizing and data management skills, including word processing, spreadsheets, data base and graphics to design and implement monitoring and evaluation tools.

PREFERRED QUALIFICATIONS: Masters of Nursing, Administration or Business. Hospital experience of at least 5-7 years in a clinical or administrative role with specific experience in quality management, performance improvement. Quality work experience of at least 3 years.

St. Johns Medical Center
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