Vanderbilt University Medical Center Sr Quality & Patient Advisor, Accreditation/Regulatory in Nashville, Tennessee

Discover VanderbiltUniversity Medical Center:

Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded and your abilities challenged. It is a place where your diversity — of culture, thinking, learning and leading — is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Your Role: This position to be filled January 2019

  • The Department ofQuality, Safety and Risk Prevention (QSRP) equips and empowers VUMC faculty andstaff to offer care that is safe, timely, effective, efficient, andpatient-centered. As a member of QSRP, this position is responsible for theengagement of Vanderbilt Health System faculty and employees to ensurecompliance with all applicable federal and state regulations.

  • Acts as a performanceimprovement engineer and patient safety manager for quality and patient safetyactivities within the Accreditation and Standards team of QSRP.

  • Provide project mgmtfacilitation, education and data analysis for improvement of organizational ordepartmental systems/processes. Assist with coordination, aggregation,analysis, and translation of info for use by leadership and improvement teams.

  • Provide leadership and coordination of majorprojects and initiatives.

  • Provide research andanalysis of Regulatory requirements, coordinates and facilitates analysis toidentify process/system flaws and assist in development of planning for processredesign.

  • Coach and mentor staffand mgmt in quality improvement, process management, and event analysis. Mentor internal staff to expand knowledge andexpertise.


  • Documents and evaluates project outcomes to facilitateorganizational memory and knowledge transfer including:

  • User challenges, needs, interests and concerns

  • Policy and procedure issues

  • Organizational changes

  • Useful communications, analysis, presentationtechniques

  • Best practices and lessons learned

  • Under minimal supervision, coordinates and oversees theevaluation and planning phases of projects

  • Organizes team resources, including steeringcommittees, projects teams and work groups as needed

  • Research evidenced based care

  • Develops high level project plan and achieves buy-in ontask responsibilities and timelines from the appropriate team members

  • Defines communications, issue management and scopemanagement strategy and achieves approval from the appropriate teammembers

  • Identifies, evaluates, documents and manages projectissues and risks and escalates, as appropriate, to achieve timelyresolution

  • Assists in defining project objectives and successmetrics

  • Creates and communicates appropriate documentation,including project overview, scope, team structure, status reports, issuemanagement reports, change control reports, and meeting notes, asdirected, in a timely manner

  • Under minimal supervision, serves as a project leaderto ensure timely completion of tasks in line with project andorganizational objectives

  • Manages and communicates project status to team membersand executive staff.

  • Provides documentation to communicate project status toteam members and executive staff, as directed

  • Identifies and documents project issues and risks andescalates, as appropriate, to achieve timely resolution

  • Ensures compliance with regulatory agencies includingmeeting deadlines, when applicable

  • Assists and/or develops measures to quantify process orquality improvements

  • Coordinates the introduction and incorporation ofquantitative or qualitative evaluation measures into project requests andevaluations

  • Assists department managers or other qualityimprovement teams in identifying, developing and monitoring outcomes

  • Assists in coordinating planning for obtaining data inevaluation measures.

  • Outlines and conveys responsibility for achievingproposed goals to appropriate persons whiles supporting and suggestingmeasures that quantify benefits.

  • Actively consults with management and/or QI teams to ensuregoals are achieved

  • Obtains data to evaluate project at completion andformally closes project.

  • Participates in improving organizational performancethrough improvement activities and process engineering

  • Collects and analyzes data

  • Provides input to departmental discussions based ondata, best practice research and benchmarking

  • Coordinate and facilitate event analysis process

  • In coordination with Risk Management and organizationalleadership, coordinate event analysis process (arrange meeting logistics)

  • Assist in the research and analysis of event

  • Assist in the development of action planning with alllevels of organizational leadership

  • Coaches and mentors staff and management and mentoringof QC's in areas such as quality improvement and process management.

  • Provides education and consultation to teams throughin-service, orientation, individual and/or group sessions

  • Maintains current knowledge of process improvementliterature and resources, and stays abreast of TJC and other regulatoryagency standards. Attends related conferences, seminars and topic-specificprocess improvement meetings

  • Department Administration

  • Supervise, manage, or participate in departmentalassignments. Handle planning, selection, logistics

  • Actively mentor other quality improvement consultantsto expand their knowledge and expertise

Position Qualifications


  • Master's Degree (orequivalent experience) and 10+ years hospital/healthcare experience; 3-5 yearsexperience in process improvement required at Vanderbilt


  • Registered Nurse

VUMC RecentAccomplishments

Because we are committed to providing the best in patient care, education and research, we are proud of our recent accomplishments:

  • US News & World Report: #1 Hospital in Tennessee, #1 Health CareProvider in Nashville, #1 Audiology ( Bill Wilkerson Center at ), 12 adult and 10 pediatric clinical specialties rankedamong the nation's best, #15 Education and Training

  • Truven Health Analytics: among the top 50 cardiovascular hospitals inthe U.S.

  • Becker's Hospital Review: one of the "100 Greatest Hospitals inAmerica"

  • The Leapfrog Group: grade "A" in Hospital Safety Score

  • National Institutes of Health: among the top 10 grant awardees for medicalresearch in the US

  • Magnet Recognition Program: Vanderbilt nurses are the only group honoredin Tennessee

  • Nashville Business Journal: Middle Tennessee's healthiest employer

  • American Hospital Association: among the 100 "MostWired" medical systems in the US


Master's Degree (or equivalent experience) and 10+ years hospital/healthcare experience; 3-5 years experience in process improvement required at Vanderbilt

Licensure, Certification, and/or Registration (LCR):

Additional Qualification Information:

  • RN preferred

Physical Requirements/Strengths needed & Physical Demands:


  • Occasional: Sitting: Remaining in seated position

  • Occasional: Standing: Remaining on one's feet without moving.

  • Occasional: Walking: Moving about on foot.

  • Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another

  • Occasional: Push/Pull: Exerting force to move objects away from or toward.

  • Occasional: Bending/Stooping: Trunk bending downward and forward by bending spine at waist requiring full use of lower extremities and back muscles

  • Occasional: Reaching below shoulders: Extending arms in any direction below shoulders.

  • Occasional: Handling: Seizing, holding, grasping, turning or otherwise working with hand or hands.


  • Occasional: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision.

  • Frequent: Noise: May include exposure to occupational noise levels which equal or exceed an 8-hr time-weighted average of 85 decibels, requiring enrollment in VUMC's Hearing Conservation Program which includes training, use of hearing protection, and periodic audiometry.

  • Continuous: Communication: Expressing or exchanging written/verbal/electronic information.

Environmental Conditions

Job Professional and Managerial

Organization: Quality,Safety&Risk Prev 60 108639

Title: Sr Quality & Patient Advisor, Accreditation/Regulatory

Location: TN-Nashville-VMG Business Office - Blakemore

Requisition ID: 1809135

Vanderbilt University Medical Center is committed to principles of equal opportunity and affirmative action.