Quality RN Analyst - Quality Management

Overview

Welcome to Montage Health’s application process!

Job Description:

Position Summary
Under the leadership of the Quality Management Director, the Clinical Quality RN Analyst helps operationalize the organization’s annual patient safety and quality program so that it supports the hospital’s strategic plan, quality commitment, and values. The role ensures compliance with hospital policies/procedures and applicable laws and standards, including The Joint Commission (TJC), California Code of Regulations, Title 22, and the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.

The Clinical Quality RN Analyst is responsible and accountable for assigned areas including policy development, routine reporting, and group/committee facilitation. Responsibilities span surveillance, prevention, and risk‑mitigation activities that reduce the likelihood and impact of patient safety events reported through the organization’s patient safety program. The Analyst facilitates and supports high‑performing teams through excellent employee and medical staff relations in a collaborative environment.

This position establishes and maintains effective working relationships with medical staff, organizational leaders, and interdepartmental partners, fostering a collaborative culture to achieve department and organizational goals. The Analyst provides regular reports to hospital Administration and the Board of Trustees and maintains current knowledge of changing regulations. The role requires active participation in Joint Commission surveys and other external regulatory inspections.

• Operationalize the annual patient safety and quality plan; maintain alignment with strategic goals and values.
• Ensure ongoing compliance with TJC, Title 22, CMS and related regulatory and payer programs (e.g., IQR, HACRP, HRRP, Leapfrog as applicable).
• Lead/participate in mock tracers, audits, and readiness rounds; maintain evidence of compliance.
• Participate actively during TJC surveys and other regulatory inspections; coordinate corrective actions and sustainment plans.
• Develop, maintain, and educate on policies, procedures, and standard work related to assigned measures and safety practices.
• Provide routine reporting to Administration, Board committees, Medical Staff committees, and quality councils.

• Own assigned inpatient measures (e.g., CLABSI, CAUTI, HAPI, falls with injury, sepsis bundle/SEP‑1, readmissions, mortality, LOS/throughput, hand hygiene).
• Perform surveillance and data validation (including inter‑rater reliability); translate findings into actionable insights for leaders and frontline teams.
• Build and maintain run/control charts, dashboards, and huddle briefs using Epic, Vizient, and Microsoft Office tools.
• Support external submissions and data integrity for relevant programs (e.g., NHSN, CMS IQR, Leapfrog) in collaboration with Analytics/IT.
• Apply statistical process control (SPC) to detect special cause variation; stratify results to close outcome gaps.

• Partner with Risk Management to review patient safety events, near misses, and grievances; perform targeted chart reviews and case tracers.
• Facilitate or contribute to RCAs/After‑Action Reviews; develop corrective action plans (CAPs) and monitor effectiveness and sustainment.
• Lead proactive hazard surveillance and failure mode identification; embed feedback loops (huddles, visual controls, standard work audits).

• Facilitate Lean Model for Improvement projects (AIM, driver diagram, PDSA cycles) at the unit and service line level.
• Coach leaders, charge nurses, educators, and physicians on measure definitions, documentation, and bundle reliability tactics.
• Design and deliver adult‑learning education (tip sheets, micro‑learning, in‑services) based on identified performance gaps.

• Lead or co‑lead relevant committees/work groups (e.g., Patient Safety, Sepsis, Falls, Pressure Injury, Throughput, Unit‑based councils).
• Prepare…