Quality Improvement/Accreditation Specialist - Quality & Risk
Southlake Regional Health Centre
Newmarket, Ontario, Canada
20h ago

Reporting to the Manager of Quality and Risk , the Quality Improvement Accreditation Specialist is responsible for enabling and promoting a proactive, integrated and just culture approach to patient safety, quality and risk management throughout Southlake.

This role is to support our Accreditation journey. The incumbent will take a leading role in the Accreditation process and will work to ensure that accreditation becomes a mechanism for continuous quality improvement and patient safety.

The incumbent will develop, execute and implement all aspects of accreditation planning cycle, providing leadership, and expertise on the process The incumbent will prepare reports for various committees and meetings providing progress updates meeting standards with variance and action plans to address gaps .

The incumbent will be responsible for the logistics for site visit in February 2020. The incumbent will support and provide education and knowledge transfer related to Accreditation standards of excellence, required organizational practices and the process to ensure organizational preparedness.


  • Leads and facilitates ongoing readiness and preparedness for Accreditation
  • Prepares updates, presentations and status reports on Accreditation
  • Coaches others on the development of action plans and how to meet standards and address gaps
  • Networks with other organizations on most effective way to meet standards. Develops strategies to embed accreditation criteria into daily work and work of existing processes and systems
  • Keeps current on accreditation requirements i.e. standards, timelines, etc.
  • Assists teams with interpretation of standards, ROPs, analysis and presentation of data
  • Prepares teams for accreditation
  • Reports on accreditation readiness
  • Creates, and disseminates work guides, tools and documents to support teams and reports for accreditation
  • Quality Improvement

  • Facilitates assigned organizational quality improvement initiatives
  • Acts as a resource to quality improvement teams
  • Collaborates with decision support team to collect data from hospital systems to identify quality and patient safety issues and to analyze data for underlying causes.
  • Facilitates patient safety / quality initiatives applying varying methods (i.e. Lean, PDSA, FMEA, project management, safeguards analysis, etc.)
  • Promotes the use of the quality improvement methods and tools for program based projects and reinforcing alignment with strategic initiatives and corporate objectives.
  • Assists teams with identifying measures, analysis and presentation of data.
  • Coordinates assigned organizational quality improvement initiatives.
  • Trains teams and individuals on the use of basic quality improvement process and tools.
  • Delivers presentations and training programs meant to increase awareness of patient safety initiatives
  • Profiles and provides knowledge transfer for quality and huddle board and the implementation of the patient safety priorities
  • Culture of Quality Improvement

  • Promotes a culture of quality and safety
  • Promotes the principles of High Reliability Organizations through education, discussion and use of terminology
  • Promotes a culture of quality through engagement, facilitation, interactions and project support with front line teams and leaders.
  • Establishes credibility with all levels of the organization to engage and influence others, by challenging the status quo and act as catalyst for positive change.
  • Leads patient safety initiatives applying various methodologies (e.g. LEAN, Model for Improvement (PDSA,) and other QI tools.
  • Plays a key role in supporting program based projects
  • Planning and Performance of Quality and Patient Safety

  • Provides insight at the program level on what data is telling us and provide guidance on how to review and analyze data
  • Keeps current of trends and issues in quality and patient safety
  • Identifies strategies to improve quality and patient safety
  • Assists with policy and procedure development i.e. conducts review of the literature, guidelines, etc.
  • Qualifications

  • University degree in a health care discipline required
  • One to three years related experience in a patient safety, risk management or quality improvement capacity required
  • Two to Three years’ experience with facilitating the Accreditation process or Regulatory process in a health care organization required
  • Membership in good standing with affiliated College or Association an asset
  • Demonstrated experience in quality improvement methods and tools i.e. LEAN, FMEA RCA, and the IHI model for improvement
  • Excellent facilitation skills
  • Strong ability to lead change through others, including utilizing influencing and conflict resolution skills
  • LEAN certification and / or a combination of courses and experience in quality improvement tools and methods and / or risk management an asset
  • Data measurement and analysis pertaining to risk, quality and patient safety
  • Demonstrated experience in project and change management
  • Superior verbal, written, listening and presentation communication skills
  • Ability to influence others and to establish credibility with all levels of the organization, challenging the status quo and being a catalyst for positive change.
  • Ability to manage multiple, often competing priorities
  • Excellent organizational, planning and time management skills
  • Excellent analytical, problem solving, negotiation and conflict resolution skills
  • Very strong attention to detail and process orientation
  • Demonstrated success in establishing, leading and maintaining positive change
  • Demonstrated ability to work independently and with multidisciplinary teams
  • Proficiency in the Microsoft suite of software, including MS Word, MS Excel, MS Project and PowerPoint.
  • Health & Safety Workplace Responsibilities :

    It is the responsibility of all Southlake Regional Health Centre employees to work in a safe manner and promote health and safety in the workplace.

    Employees must adhere to the duties of workers, as stipulated in Section 28 of the OH&S Act, as well as all Southlake OH&S policies and procedures.

    Must be able to perform all necessary bona fide duties for the position, as outlined in the position guide. Must review and be capable of performing duties the Job Demands Analysis for the position as a condition of offer.

    Proven ability to attend work regularly as per the Attendance Support Policy.

    Accommodation & Diversity in the Workplace

    At Southlake, we are committed to fostering an inclusive and accessible work environment. We are dedicated to building a work place that reflects the diversity of our community in which we live and serve, including those with disabilities, visible minorities, aboriginal persons, members of sexual minority groups and others who may contribute to diversity within our organization.

    Southlake is committed to the principles of the Accessibility for Ontarians with Disabilities Act (AODA), and will work proactively through all stages of recruitment to create a barrier free process and to provide accommodation as required.

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