Home / Quality Specialist (Full Time/ Day Shift)

Quality Specialist (Full Time/ Day Shift)


1st Shift

Job Description

POSITION SUMMARY: The Quality Specialist  works collaboratively with organizational and physician leadership, to develop  and maintain processes and systems needed for highly reliable organizations, including  consistent quality standards and a state of continual readiness and vigilance regarding system-wide compliance related to State and Federal regulations and Joint Commission standards. Serves as an active collaborator with operational leaders, bridging inpatient and ambulatory services to build commitment for quality, safety and the delivery of high, quality care - to support ongoing active rounding practices, as well as a liaison to the front line staff to identify opportunities for quality improvement, and development of monitoring adherence to process changes for sustainability. Provides data management support for compliance to action plans, and supports tracking/trending consistent with the organizations quality goals and imperatives.

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.

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

  • 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



  • 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.
  • Master of Science degree in Nursing or other related Master’s degree (or enrolled currently in program with completion date estimated to be within the next 6-9 months)
  • 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.
  • CPHQ certification, CPPS certification, CMQ/OE or other related patient safety or quality certification within 30 months of hire date
  • 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.


  • Five (5) years’ experience and expertise with maintaining regulatory, safety and quality standards within an acute 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


WORKING CONDITIONS: Position involves exposure to the following harmful elements:

  • Bio hazardous Waste
  • Blood borne Pathogens
  • Chemicals
  • Extreme Noise Levels
  • Extreme Temperatures
  • Exposed Electrical Lines
  • High Pressure Steam/Gas
  • Moving/Rotating Machinery
  • Radioactive Agents


Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.  It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards.  The percentages of time spent performing job duties are estimates, and should not be considered absolute.  The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole.  Incumbent must be able to perform all job functions safely.


Benefits At A Glance:

PENN MEDICINE LANCASTER GENERAL HEALTH offers the following benefits to employees:

  • 100% Tuition Assistance at The Pennsylvania College of Health Sciences
  • Paid Time Off and Paid Holidays
  • Shift, Weekend and On-Call Differentials
  • Health, Dental and Vision Coverage
  • Short-Term and Long-Term Disability
  • Retirement Savings Account with Company Matching
  • Child Care Subsidies
  • Onsite Gym and Fitness Classes


PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.


Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.

LGH Full Time Posted on 08/25/2023