Clinical Performance Improvement Specialist

Whatever the role, everyone at Grady is part of something bigger. Choosing a career at Grady is choosing to be part of a legacy of service and commitment to our communities. If you want to make a difference, we want to hear from you.

Job Summary The Clinical Performance Improvement Specialist/Sepsis Coordinator manages clinical performance improvement (CPI) and quality activities for the health system. This position interacts with physicians, administrative leaders, and other clinical staff and provides support and guidance to clinical improvement initiatives. This CPI Specialist is responsible for assisting the organization in adopting best practices to include alignment with the Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS).

Performance Improvement Planning and Facilitation (50%)

• Collaborate and partner with unit leadership and staff to develop and implement the Grady Quality and Performance Improvement (QAPI) plan. Ensure that the implementation of the plan is aligned with Grady Health System True North and Grady Health System goals.

• Coach and assist unit teams to identify appropriate and meaningful area and unit-specific priorities, improvement opportunities, and quality metrics.

• Collaborate and partner with leaders and staff to organize the work to achieve annual quality, patient progression and patient experience goals.

• Develop A3s, convene and facilitate tactical teams, design and implement project tracking of process and outcome measures, utilize PI methods/tools to test and implement improvement interventions, and provide project and change management facilitation and coaching.

• Collaborate and partner with leadership to submit quarterly data and updates and compile annual plan evaluations.

• Work with data analysts to ensure that units have access to timely and accurate performance data to support their projects and institutionally aligned improvement work.

• Prepare presentations and reports, as requested and as required, for various oversight and governance committees as related to performance improvement work.

• Participate on teams, committees, and tasks forces as appropriate.

Clinical Data Review and Analysis (20%)

• Conduct focused event reviews and data analysis to determine causal factors and gaps related to key performance targets and measures or when there is special cause variation. Utilize appropriate visual graphical tools and data displays (including SPC charts) to provide interpretation ease and meaningful conclusions. Utilize more advanced statistical tools and analysis when appropriate.

• Compile data and narrative reports that summarize findings, determine causes, and make recommendations for improvement. Compile reports and presentations that summarize improvement projects and successful improvement activities.

• Serve as a subject matter expert regarding elements needed to meet quality reporting measures and metrics requirements.

Quality Management Knowledge and Expertise (20%)

• Maintain current knowledge of relevant quality tools, standards, rules, regulations, and requirements.

• Maintain current knowledge of quality and safety indicators as they pertain to assigned units/service line(s).

• Maintain current knowledge of benchmarking frameworks and methodologies including CMS and Vizient.

• Maintain current knowledge of relevant databases and registries including the Vizient Clinical Data Base.

Regulatory and Accreditation (10%)

• Maintain current knowledge of relevant regulatory and accreditation standards and requirements.

• Assist with regulatory visits by providing support with data, policies, documentation, physical presence and participation.

QUALIFICATIONS

• Bachelor of Science degree in Nursing/Graduate of an accredited Nursing Program/Physician Assistant/Medical School Program.

• Five (5) years of health care experience, with two (2) years preferably in Clinical Quality Management, Case Management or Clinical Education

• Experience reviewing data from medical records and turning it into actionable information

• Experience in acute care setting strongly preferred

• Comprehensive knowledge of quality improvement philosophy, methodologies, applications

• Proficient in Microsoft Word, Excel and Powerpoint.

• Certified Professional in Healthcare Quality (CPHQ) certification preferred

Core Competencies These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

1. Patient-Centered Care – Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
2. Integrity & Accountability – Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
3. Collaboration & Teamwork – Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
4. Communication – Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
5. Respect & Inclusion – Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
6. Quality & Safety – Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.
7. Adaptability & Resilience – Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
8. Continuous Improvement – Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
9. Leadership & Professionalism – Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
10. Employee Experience Focus – Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

• Health & Wellness: Medical, dental, vision, and prescription drug coverage.

• Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.

• Work-Life Balance: Paid time off, holidays, and family leave benefits.

• Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.

• Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady’s Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady? Grady Health System is more than a hospital — we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don’t just work, we make an impact.

Equal Opportunity Employer Statement: Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.