Works collaboratively with and assists the AVP, Clinical Quality, with all aspects of JCAHO, CMS and TDH compliance, continuous readiness, education and action plans Works collaboratively with and assists the AVP, Clinical Quality, with all aspects of National Patient Safety Goals compliance, continuous readiness, education and action plans Works collaboratively with and assists the AVP, Clinical Quality, in the facilitation of quality improvement initiatives and activities Works collaboratively with and assists the AVP, Clinical Quality, in the facilitation of peer review and procedure appropriatenss initiatives and activities. What you will do in this role: Responsible for and provides leadership for Core Measure data collection, analysis and related organizational education Coordinates data collection activities and processes related to hospital based report cards, SIM + reviews, peer review and other related projects Provides leadership for select Root Cause Analysis activities to include review, planning, education and action plans Provides and coordinates education and training to new quailty staff related to data collection, review and processing.