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Description
Under the direction of the Hospital Quality Improvement Manager, plans, coordinates, and implements quality improvement activities as required by State, Federal, and Joint Commission on Accreditation of Health Care Organizations (JCAHO) regulations and requirements for Santa Clara Valley Medical Center (SCVMC).COVID-19 Risk Tier – Department-specific determination based on each specific position. Learn more about Santa Clara Health System at:scvmc.org, och.sccgov.org, slrh.sccgov.org, valleyhealthplan.org Twitter I @scvmctalent Facebook I facebook.com/SCVMC LinkedIn | linkedin.com/scvmcJob Subscription | Sign Up Twitter I @vhphealth Facebook I facebook.com/valleyhealthplan LinkedIn | linkedin.com/valley-health-plan
Typical Tasks
Monitors SCVMC departments to ensure compliance with the Quality Improvement Plan;
Coordinates division and department quality improvement activities, including surveys and mock audits;
Ensures that standards, policies, and procedures are consistent with professional standards and requirements as defined by JCAHO and other regulatory agencies;
Assesses quality improvement training needs; plans and implements training for support staff;
Participates in organizational and departmental committees and task forces;
Develops systems and procedures to meet the internal goals and objectives of the Quality Improvement Plan;
Collaborates with medical, nursing, and professional staff to plan quality improvement activities and resolve identified problem areas;
Maintains current knowledge of organizational goals and objectives;
Promotes and facilitates process/quality improvement teams within the organizations;
Collaborates with hospital administrative support officer regarding organizational standards, policies and procedures;
Initiates changes in standards, policies, procedures and practice based on quality improvement review;
Interprets policies and regulations to medical, nursing, and professional support staff;
Promotes compliance with legal and regulatory requirements;
Plans accreditation and regulatory surveys, prepares responses/reports based on reports of findings;
Collaborates with Risk Management regarding risk/quality issues;
Identifies local and national trends applicable to quality improvement standards;
Evaluates the feasibility of new programs to enhance compliance with standards;
Acts as a resource for quality improvement activities;
Performs concurrent and retrospective chart reviews and analysis for selected department and organizational indicators;
Collaborates with Utilization Management, medical staff, nursing, and professional support staff in the development, implementation and evaluation of Patient Care Guidelines;
Initiates and participates in research related to standards, quality improvement, and risk management, utilizes research to support changes of standards and practice;
Perform other duties as assigned.
Employment Standards
Possession of a California Registered Nursing license.Experience Note: The knowledge and abilities required to perform this function are typically acquired through training and experience equivalent to four (4) years of experience in an acute care hospital setting. Nursing management experience is desirable but not required.Knowledge of:
Hospital organization, operation and procedures;
Federal and State health care laws and regulations common to the operation of hospitals in California;
Regulations of intermediary agencies pertaining to hospital stay coverage (e.g. Medicare and MediCal);
Quality improvement and risk management standards, policy, procedures and protocols;
Current trends, issues, research in Quality Improvement in a large medical services system;
Standards, policies, procedures, and medical protocols in a healthcare setting;
Joint Commission Accreditation standards and Title XXII requirements and Federal regulations;
Regulatory requirements for acute care hospital and ambulatory care settings;
Medical terminology and related levels of care and treatment;
Methods, regulations, and procedures for research within a healthcare setting;
Evaluation and assessment techniques;
Record keeping and reporting procedures.
Ability to:
Analyze data, write reports, and evaluate improvement programs and activities;
Evaluate and interpret complex medical regimens pertaining to quality of care standards;
Plan, develop, and organize work;
Communicate effectively, orally and in writing; with all levels of professional and non-professional staff, and executive management;
Develop personal and professional quality improvement goals;
Facilitate Quality Improvement teams to implement quality improvement goals and standards;
Plan and implement quality improvement educational activities for medical, nursing, and professional support staff;
Maintain current knowledge of trends/practices in Quality Management.
