Safety, Quality and Patient Experience - Sepsis

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