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Assists the Director in maintaining and revising the Medical Center Quality Improvement program. Coordinates the activities of departments, committees and medical staff to develop and document ongoing evaluation activities; perform studies and problem focused reviews; interpret data and promote the Medical Center Quality Improvement Program to medical, nursing and support services. May assume role of Director when necessary.
Consults with Service Line Leaders, Chiefs of Service, Medical Staff Committee Chairpersons, Physicians and Department Administrators in charge of special care areas to assist them in developing ongoing evaluation programs to identify, resolve, and report opportunities to improve patient care.
May represent the Department on Medical Staff committees.
Designs, conducts and evaluates studies and problem focused reviews requested by the Medical Center Administration, medical staff, or department administrators which frequently involve sensitive, confidential, or medical legal issues.
Performs and oversees ongoing Quality Improvement activities across the medical center to assure timeliness, accuracy and compliance with licensing and regulation requirements.
Use and educate end users on data display tools, including statistical process control methods.
Participate in risk management by investigating problems encountered by patients, identifying patterns and trends in patient care problems, and developing policies and procedures to reduce risks.
Monitors compliance with quality improvement requirements.
Assist in the supervision and direction of the activities performed by the Quality Improvement Analysts and support staff.
Assist in the preparation of the Quality of Care reports that are sent to the Region offices and the Board of Directors.
Develop and conduct presentations on the quality improvement standards and the Medical Center Quality Improvement Plan to insure compliance with TJC, NCQA and other regulatory agency standards.
Conducts special clinical studies related to patient care management.
Participate in the annual development of the Medical Center goals for Quality Improvement.
Minimum two (2) years of experience as a licensed hospital nurse required.
Minimum one (1) year of experience in quality-related activities.
Graduate of an accredited school of nursing required.
License, Certification, Registration
Current California RN license required.
Experience in a "patient advocate" role to insure a "patient" centered focus.
Familiarity with medical procedures and terminology.
Strong planning, organizing, interpersonal and conflict resolution skills.
Detailed knowledge of Title 22, TJC and NCQA requirements for licensure and accreditation.
Proficient with PC applications including database, spreadsheet, and word processing.
Must be able to work in a Labor/Management Partnership environment.
Experience in a quality improvement related role, including leading/facilitating teams in performance improvement.
Bachelor's degree in nursing or health care preferred.
Current Certified Professional of Healthcare Quality (CPHQ) preferred.