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Department:
Quality Management

Under the supervision of the Senior Administrative Director, Quality Management Department and /or Manager of the specific department, provides clinical, technical, and analytical support and evaluation of operational processes and statistical data necessary to support performance improvement processes. Effectively facilitates interdepartmental and/or interdisciplinary performance improvement teams in order to support organization wide performance improvement activities.

1. General

• Staff Resource/Educator
• Functions as a resource/educator for performance improvement processes and/or structured problem-solving approaches.
• Assists Department leaders with development of intra-, interdepartmental processes to improve the efficiency, effectiveness, and safety of patient care and departmental operations.
• Attends facility committees as assigned by the Department Manager.
• Manages time to ensure that workload for multiple projects is completed within the required time frame.
• Utilizes quality databases to collect and analyze data accurately.
• Demonstrates motivation and ambition on the job, adapts to and supports change, independently seeks unassigned work without impacting quality, is flexible, thinks along original lines, questions old methods and offers suggestions for improvement of procedures.

2. Division of Quality Services

• Coordinates interdepartmental, interdisciplinary process/performance improvement initiatives.
• Effectively facilitates multiple performance improvement teams, including evaluating processes to improve efficiency and cost effectiveness.
• Designs and conducts special PI projects as required / requested.
• Assists organizational staff with development and implementation of process improvements.
• Assists leadership with creation / management of department or project specific data needs via software program reports to assist in defining dashboards / scorecards.
• Ensures improvement team targets are consistently met or exceeded within the required time frame.
• In collaboration with the Regulatory Division, participates in Comprehensive Analysis teams, Safety Alerts and manages follow up on Action Plans.
• Data Collection/Analysis
• Develops data collection forms/processes. Collects and analyzes data to performance of processes and staff, and adherence to established policies/procedures. Communicates provider specific data to the Department Director for recognition and/or follow-up as appropriate.
• Perform medical record review for data collection and submission. Works with the interdisciplinary team, including physicians to facilitate improvement based on data analysis.
• Attends hospital departmental staff meetings to communicate results of improvement initiatives.
• Assist with the creation of the assigned department specific organizational dashboards / scorecards.
• Medical / Nursing Staff Peer Review
• Functions as a resource for medical / nursing peer review according to the policy/processes.
• Effectively communicates with Committee Chair(s) and members as necessary.
• Conducts special studies and/or focused reviews as requested.
• Accurately screens cases for peer review committees.

3. Division of Patient Safety

• Manages the patient safety reports on an ongoing basis to assure timely completion and closure.
• Collaborates with other PI Specialists to identify and facilitate PI projects based on occurrence report trends and patterns
• Tracks and trends all incidents in collaboration with the Patient Safety Organization (PSO) requirements. Submits timely reports to the PSO.
• Meets routinely with Department leaders to identify patient safety issues / concerns and assist with the PI improvements.
• Provides reports to the departments leaders on department specific occurrences as requested.
• Provides reports for facility committees as requested.
• Assists the Enterprise Risk Manager in conducting comprehensive analysis for adverse events.
• Conducts patient safety rounds routinely.

4. Department of Regulatory and Accreditation

• Assists the Manager with all regulatory and accreditation activities for the facility as assigned.
• Conducts patient tracers as assigned to assure readiness for survey. Completes reports for Regulatory Oversight Committee.
• Participates on PI teams as requested.
• Policy/Process
• Participates in policies/procedure development as requested based on analysis of data.

5. Miscellaneous

• Complies with all applicable health system polices and procedures.
• Performs other duties as assigned.

Education: Bachelor's degree, preferably in a healthcare discipline required. Master's degree preferred.

Licensure: Current California Registered Nurse (RN) license. Previous acute care experience required in the past 10 years. Out of state RN license have 1 year from date of hire/transfer to obtain a California RN license. Certified Professional in Healthcare Quality (CPHQ) or CPHQ eligible preferred. Lean Management/Six Sigma Greenbelt or higher preferred

Experience: At least 3 years direct experience with process improvement, and use of facilitation tools/techniques such as agenda planning, group facilitation and decision-making, brainstorming, multivoting, and prioritizing required Direct experience in a healthcare profession or dealing with clinical healthcare providers across a healthcare organization required. Demonstrated experience managing cross-functional clinical teams required.

Pay Range: The hourly rate for this position is $72.45 - $90.00. The range displayed on this job posting reflects the target for new hire salaries for this position.

Job Specifications:
• Union: Non-Affiliated

• Work Shift: Day Shift

• FTE: 1.0

• Scheduled Hours: 40

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!