Clinical Quality and Patient Safety Coordinator

Ephrata, PA | Professional | Tracking Code: 72884

Job Description:


Under the general supervision of the Regional Director-Quality Improvement, with matrix reporting relationship with the Hospital Patient Safety Officer, uses data for healthcare quality and safety measures to review for trends and gaps related to documentation of clinical practice, established clinical staff quality improvement procedure and peer review indicators, and quality and patient safety performance. Performs Electronic Health Record review and research of patient safety related events and provides a brief clinical summary of the findings. Elevates and communicates gaps and opportunities with improvement recommendations through established channels to improve care quality and safety.


Duties and Responsibilities


  1. Clinical Quality Accountabilities
  2. Reviews quality and patient safety measure data for trends and data summary to focus any necessary record review. Provides critical information in quality improvement for the patients to the Hospital’s Vice President of Medical Affairs (VPMA).
  3. Utilizing the Quality Accountability Model and related QIRS scoring system, communicates with patient caregivers to alert them regarding progress to goals, targets and regulation requirements. Coaches staff regarding the expected documentation and care guidelines. Educates to measure definitions when sharing data. Facilitates conversations and assists staff to identify and translate quality outcomes into a change in practice (e.g., policy, procedure, process, protocol, etc.).
  4. Researches and analyzes requests (using knowledge of the system network and internal and external resources) for possible process improvement/quality improvement opportunities, as assigned by the VPMA or Regional Director.
  5. Patient Safety Accountabilities
  6. Reviews patient medical records for compliance with established medical staff quality improvement/peer review indicators, enters cases with non-compliance into the web-based peer review tracking system and assigns cases for peer review in accordance with established procedures. Acts as primary administrator for the web-based peer review tracking system, uses peer review tracking system to prepare agenda materials for the medical staff quality improvement/peer review committees, and completes clinical follow-up correspondence and actions from the medical staff quality improvement/peer review committees in an accurate and timely manner.
  7. Reviews patient medical records associated with patient safety events in the web-based event reporting system and ensures that appropriate action is taken to address the events, including documentation in the event reporting system and compliance with internal and external reporting and notification requirements.
  8. Keeps Patient Safety Officer and Regional Director informed of any potential reportable patient safety event and potential areas of improvement from patient safety or medical staff quality improvement/peer review perspective.
  9. Provides consultation regarding data analysis and interpretation to clinicians, leadership and others. Works collaboratively to provide consistent, meaningful information to all levels of the organization, including the information provided to the Hospital Board of Directors.
  10. Uses problem analysis skills and critical thinking to collect and analyze data, propose solutions, develop and write reports, letters and materials needed to achieve desirable results as requested. Able to manage advanced database and spreadsheet applications (e.g., formulas, linking calculations, graphing and reporting) as well as web-based systems needed to obtain or manage clinical information.
  11. Provides data abstraction from the Electronic Health Record, for needed Hospital measures, as needed and with high quality and good timing.




  • Notes:
    • Other combinations of formal education, training and experience may be considered.


  • Minimum Experience:
    • 2 years of experience in adult inpatient medical/surgical or critical care. Experience in electronic health record review is preferred.


  • Minimum Education:
    • Graduate of an accredited nursing program


  • Required Certification:
    • Current RN license in PA


  • Skills:
    • Excellent computer skills, including word processing, internet, data entry, and spreadsheet use, and the ability to efficiently use numerous web-based systems to obtain and take appropriate action relative to clinical information. Good interpersonal skills. Analytical skills necessary to clinically assess medical records and apply internal and external criteria. Excellent prioritization and organizational skills.
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Lancaster City was the capital of Pennsylvania from 1799 to 1812. Today, Lancaster County includes a vibrant downtown business district, desirable suburban neighborhoods and sprawling agricultural farms. Life in Lancaster County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, an independent professional baseball team, fine dining and more. When visiting Lancaster, one can't help but recognizing the influence of the Pennsylvania Dutch — farm-to-table and beyond.

Conveniently located in southcentral Pennsylvania, Lancaster is within an easy commute to major cities and has ready access to public transportation. Residents can find local employment in healthcare, tourism, public administration, manufacturing, and both professional and semi-professional services. (Patient population: 535,000)