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Quality Specialist


Lancaster General Hospital

Cost Center

9060 Quality Improvement

Supervisory Organization





This position is located in Lancaster, Pa

HOURS: Full Time- Weekdays

The Quality Specialist leads improvement efforts in quality, patient safety, infection control, and regulatory/accreditation across Lancaster General Health through collaboration with the medical staff, operational leaders, and executive leadership.  This role supports a culture of high reliability to achieve safe, reliable, and effective care.  The Senior Quality Specialist provides leaders the necessary tools and support to better understand the problem that they are trying to solve, identify the most appropriate improvement tools to utilize, and implement experiments to solve the problem and drive improvements in the outcomes

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

  • Maintains a strong working knowledge of current regulations and quality standards for all state, Federal and Joint Commission patient safety and quality requirements both in the acute care hospital system and ambulatory settings. Effectively communicates any changes in interpretation to appropriate organizational leadership as directed by Accreditation and Regulatory standards team, and provides coaching to develop action plans as needed to assess, monitor and comply with current changes.
  • Assists in collecting data, creating reports, interpreting and analyzing data in order to support leaders in identifying both gaps in performance and regulatory compliance, opportunities for improvement and sustainability of action plans. Collaborates with Performance Optimization to support quality improvement initiatives through process standardization and use of the scientific method, including consistent application of A3 methodology/thinking. Connect applicable measures and metrics to departmental daily improvement boards.
  • Serves as an embedded local resource for designated or developing UPHS Quality, Safety and Regulatory programs and initiatives and maintains a working knowledge of health system networking capabilities to ensure alignment across all Penn Medicine and partner facilities.
  • Collaborates with the medical, clinical and operational leaders at all levels (executive, director and front line) to foster a culture of engagement, collaboration and shared accountability to ensure a state of perpetual readiness. Facilitates activities to support alignment of quality efforts in connection to the organizational strategic plan. Combines knowledge of accurate assessment techniques utilizing direct problem observation, documentation in the medical record, staff interview, and guided onsite process observations (readiness rounds) to facilitate teams toward fixing reoccurring issues and eliminating patient/employee safety concerns through the use of concurrent problem solving.
  • Collaborates with all supporting functions including, but not limited to Performance optimization, Environmental Safety, and Information Services to promote design and compliance to processes needed to support a highly reliable organization, which often requires crossing departmental and organizational boundaries, including primary, specialty care practices aligned within the organization’s population health efforts.
  • Active participation within various committees or taskforces launched for quality improvement initiatives, ensuring integration of current, evidence based knowledge, pay for performance governmental and third party payer requirements, and The Joint Commission ORYX performance measure reporting requirements.
  • Support research efforts both locally, at UPHS, nationally and globally as requested which may include assisting in development of data collection tools, surveys, and active participation in logistics to further evidence to promote quality and safe care for all populations.
  • Maintain a working knowledge of principle and practices of quality improvement, team facilitation, problem solving, change management, medical terminology and navigation of the electronic medical record.
  • Maintain ongoing capabilities of electronic management information systems, including word processing and spreadsheet application and data base programs (i.e. Microsoft Word, Excel, Midas and Vizient)
  • Other duties as assigned


  • Bachelor of Science degree in Nursing or other related Bachelor’s degree
  • Minimum of three (3) years leading and/or participating in quality improvement and safety programs, including facilitating teams through state or/and federal QIO (Quality Improvement Organization) initiatives or pay for performance processes.
  • Knowledge of quality improvement models – such as IHI Model for Improvement, TeamStepps, Lean Management System – Toyota Productions System (TPS), Shingo model or safety experience within healthcare or related field.
  • Successful completion of any Penn Medicine – Lancaster General Health training requirements for organizational leadership regarding Lean Management systems, or other related improvement tools to ensure alignments with organizational priorities and required leadership behaviors within 6 months of hire.
  • Proficiency with all Microsoft Office products including Word, Excel and project management tools. Ability to utilize data to visually indicate areas needing quality improvement efforts.
  • Thorough capabilities with both oral and written communication skills, as well as coaching behaviors needed to work with both front line staff, medical and organizational leaders.


  • CPHQ certification or other related patient safety or quality certification
  • Master’s degree in related field
  • Five (5) years’ experience and expertise with maintaining regulatory, safety and quality standards within a healthcare or industrial setting. Three (3) years in a leadership role within that field
  • Experience with statistical software and/or other data analysis and visual display of data

LGH Full Time Posted on 02/18/2020