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Spaulding Rehabilitation Quality Specialist in Brighton, Massachusetts

Quality Specialist - ( 3273530 )


This position is 32 hours/week and has a hybrid work schedule with 1 day/week remote.


The Senior Quality, Safety, PFR and Compliance Specialist leads and performs day to day activities related to performance improvement, patient safety, risk management, patient experience, and hospital accreditation. Regulatory compliance activities include audits and investigations, developing and shepherding action plans, and conducting related educational programs.

Key Responsibilities

  • Safety occurrence reporting system and case analysis related to adverse events are managed in accordance with department and regulatory guidelines.

  • Patient and Family Relations program is implemented and monitored to achieve stated goals.

  • Responsible for incoming calls, visits and correspondence to serve as a liaison between patients, loved ones, and staff in acknowledging and responding to feedback (complaints/grievances/compliments) and other requests in a compassionate and supportive manner. Utilizes data management system to meet regulatory requirements for CMS, DPH and The Joint Commission for complaint management and resolution process.

  • Performance improvement and patient safety activities implemented to address quality concerns identified through hospital systems or by external reviewers to meet expected outcomes.

  • Accreditation survey preparation and coordination is provided to ensure regulatory compliance.

  • Facilitate completion of required evidence of standards compliance action plans following survey activity.

  • Chair and/or participate in quality related committees to ensure safe patient care and exceptional patient experience.

  • Staff education is provided to build organizational capability.

  • Special projects and counsel are provided to department managers as needed to maintain compliance with organization and regulatory standards.

  • Potential quality or compliance concerns identified internally through hospital systems or by external reviewers (i.e., quality improvement organization, managed care providers, referring facilities) are evaluated via clinical chart review and data collection, with analysis of aggregate data and development of reports.

  • Additional department, organization, or network activities are completed per established objectives.

  • Implement Quality improvement work in both the hospital and skilled nursing facility setting per network goals.

  • Assist with completion of the annual Patient Care Assessments and submit to the BORM Quality and Patient Safety Division.

  • Because this role in an active change management environment, this specialist will need to demonstrate flexibility and open mindedness as the contours of this position will actively evolve over time.

  • Other duties as assigned.


Qualifications and Experience



  • Bachelor’s degree in nursing, therapy or other clinical field required.


  • Education and/or experience with both hospital and long term care settings.



  • Minimum of two years experience with quality, safety and compliance in a healthcare setting.

  • Experience with accreditation surveys such as Joint Commission and/or CARF.


  • Three to five years related experience preferred.



  • Current Massachusetts’s license as Registered Nurse or other health care professional required.


  • Certificated Professional in Healthcare Quality, Certified Professional in Healthcare Risk Management

Skills (Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS, etc.)


  • Computer proficiency required. Microsoft office applications preferred with ability to learn new software.


  • Ability to analyze data and make recommendations for improvement.

  • Ability to create PowerPoint presentations and present to a variety of audiences.

  • Highly developed communications and interpersonal skills, working with diverse population.

  • Work independently, be self-directed and contribute as a member of a team.

  • Anticipates challenges and develops and implements strategies for addressing them.

  • High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations.

  • Attention to detail. EEO Statement:

SRN is committed to diversity in the workplace which begins with respect and opportunity for all. SRN takes affirmative action to ensure that equal employment opportunity is provided to all persons regardless of race, religious creed, color, national origin, sex, sexual orientation, gender identity, genetic information, age, ancestry, veteran status, disability or any other basis that would be inconsistent with any applicable ordinance or law. If you need a reasonable accommodation in coming to or participating in the interview process, please let us know.

Primary Location : MA-Brighton-SRH Spaulding Brighton

Work Locations :

SRH Spaulding Brighton

100 North Beacon Street

Brighton 02134

Job : Professional/Managerial

Organization : Spaulding Nursing & Therapy Ctr - Brighton (SRN and SRB)

Schedule : Part-time

Standard Hours: : 32

Shift : Day Job

Employee Status : Regular

Recruiting Department: : SHC Compliance & Outcomes

Job Posting : Feb 2, 2024

Req ID: 3273530