Job Summary

The RN – Quality Analyst is responsible for collecting, analyzing, and reporting clinical and operational data to support performance improvement and regulatory compliance

This role collaborates with clinical leaders, medical staff, and quality teams to identify trends, facilitate improvement initiatives, and prepare for accreditation and regulatory surveys

The Quality Analyst uses clinical expertise and data analysis to improve patient safety, care quality, and organizational outcomes

Essential Functions

Collect, organize, and analyze clinical performance data to support hospital-wide quality initiatives

Perform statistical analysis and generate reports to identify opportunities for improvement

Review and interpret internal and external data sources including incident reports, core measures, and regulatory benchmarks

Collaborate with leaders and staff to present actionable data for risk analysis and performance tracking

Serve as a resource during performance improvement and patient safety committee meetings

Participate in sentinel event reviews, root cause analysis, and near-miss event reviews

Maintain databases related to quality indicators and improvement projects

Support data submission for CMS, The Joint Commission, and state regulatory agencies

Format data into charts, graphs, summaries, and reports to support effective decision-making

Stay current with accreditation standards and recommend updates to data collection or reporting tools

Assist with survey readiness and onsite preparation for regulatory visits

Provide guidance and support to leadership on regulatory data requirements and quality trends

Knowledge/Skills/Abilities/Expectations

Proficient in Microsoft Excel, Word, PowerPoint, and quality data systems

Strong understanding of healthcare quality concepts, performance measurement, and regulatory compliance

Excellent verbal, written, and presentation skills

Strong organizational and time management skills with the ability to manage multiple priorities

Ability to work independently and as part of a cross-functional team

Familiarity with Joint Commission standards, CMS quality programs, and national benchmarking data

Frequent sitting, computer work, and document handling

Occasional walking, standing, and reaching

Ability to lift up to 10 pounds occasionally

Visual and auditory acuity required for data review and communication

Office and clinical areas within a healthcare facility

May require participation in patient care unit observations and quality rounds

Frequent use of computer monitors and data systems

Qualifications

Education

Associate degree in Nursing required

Bachelor of Science in Nursing (BSN) preferred

Licenses/Certifications

Current Registered Nurse (RN) license in the state of practice required

Certification in Quality (e.g., CPHQ) preferred

Experience

Minimum two (2) years of clinical healthcare experience required

Experience in performance improvement, data analysis, or quality/risk management preferred

Coursework in statistics, data analysis, or performance improvement desirable