RN Quality Improvement Coordinator

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

RN QUALITY IMPROVEMENT COORDINATOR

Job Description:

Beth Israel Deaconess Hospital-Plymouth recognizes Integrity, Respect, Trust, Teamwork and Excellence as the Core Values of our organization.  It is the philosophy of BID-Plymouth to follow the LEAN methodology in order to provide the full continuum of health care services and the best quality patient centered care.

Position Summary: Under the supervision of the Quality Improvement Manager, the RN Quality Improvement Coordinator plays a vital role in advancing patient care outcomes and experiences at BID-P. This role leads performance improvement initiatives using evidence-based methodologies, fosters a culture of continuous learning, and supports clinical teams in achieving excellence in quality and safety.

This position blends clinical expertise, data analysis, project leadership, and collaborative engagement to improve hospital-wide performance metrics and meet regulatory requirements.

Duties/Responsibilities:

• Lead, support, and sustain quality initiatives aimed at improving:
  • AHRQ Patient Safety Indicators
  • Expected Complication Rate Index
  • Risk-Adjusted Mortality Index
  • Hospital-Acquired Conditions
  • Core Measures, Value-Based Purchasing, Meaningful Use, and other indicators
• Serve as a subject matter expert on publicly reported data including:
  • IQR, OQR, IPFQR, MassHealth, TJC, e-CQMs
  • Clinical registries such as GWTG, NCDR, and others
• Support Q-Centrix abstraction processes, ensuring clinical data accuracy for Core Measures, e-CQMs, registries, and additional reporting requirements
• Apply performance improvement methodologies such as Lean, Six Sigma, and PDSA to drive process efficiency and outcome improvements
• Collaborate with physicians, nurses, documentation specialists, and coding teams to optimize documentation, care delivery, and metric performance
• Analyze and translate quality data into reports, dashboards, and educational materials for committees and leadership
• Participate in quality-related committees, review best practices and evidence-based literature, and benchmark against national and regional standards
• Assist in evaluating care processes, developing indicators, and tracking performance to meet quality goals
• Support the hospital’s Continuous Quality Improvement Plan and ensure compliance with TJC, CMS, and other accrediting bodies
• Develop and assist in implementing corrective action plans and policy revisions based on findings or regulatory updates
• Foster a collaborative, team-based environment focused on continuous improvement and innovation
• Facilitate service-line level Quality Committees and Morbidity and Mortality Conferences

It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Education/Experience Required:

• Bachelor’s degree in Nursing (BSN) – required
• Master’s degree in a healthcare-related field – required
• At least 2 years of progressive experience in quality improvement, compliance, accreditation, or related healthcare roles
• Experience leading complex, cross-functional projects in a clinical or hospital setting
• Strong knowledge of performance improvement and quality methodologies (e.g., Lean, Six Sigma, PDSA, RCA, FMEA)
• Familiarity with accreditation and regulatory standards (e.g., TJC, CMS, MassHealth)
• Advanced data analysis and reporting skills; able to interpret complex datasets and identify trends
• Excellent oral and written communication skills
• Skilled in Microsoft Office (Excel, PowerPoint, Word); EPIC experience preferred
• Ability to build and maintain effective working relationships across all levels of the organization
• Strong organization, prioritization, and project management skills
• Self-motivated, detail-oriented, and able to work independently while supporting a team environment
• Demonstrated commitment to upholding the mission and values of Beth Israel Deaconess Hospital–Plymouth

Registration/Certification:

• Current Massachusetts RN license – required
• Certified Professional in Healthcare Quality (CPHQ) – preferred or obtained within 1 year of employment
• Lean Six Sigma Green Belt or higher – preferred

Physical/Environmental Requirements

This job requires frequent bending, carrying, pulling, pushing, reaching, standing, stooping, walking and lifting over 10 lb