Under general direction, performs responsible program development and coordination work to implement and maintain the San Joaquin General Hospital Quality Improvement program; and does related or other work as required in accordance with Rule 3, Section 3 of the Civil Service Rules.
An incumbent of this single position class develops, plans, organizes, implements, coordinates, monitors and maintains the Hospital Quality Improvement program. This includes quality improvement functions and activities of the medical staff, nursing staff, and the ancillary departments of the hospital. General direction is received from senior administrative staff.
Develops, plans, organizes, coordinates, implements, reviews, and maintains Quality Improvement Program functions and activities for San Joaquin General Hospital, including the medical and nursing staff and the ancillary departments.
Identifies and assesses quality and related risk issues, and collaborates with appropriate staff to prepare corrective action plans in response to these issues.
Selects, supervises, assigns, and evaluates nursing and/or clerical staff in the department.
Acts as liaison with outside agencies in quality improvement matters; provides direction to the hospital's quality improvement committees; supervises or participates in the preparation of committee reports, correspondence, agenda and meeting minutes; attends medical staff or hospital conferences and meetings as assigned to represent quality improvement.
Meets regularly with medical staff department chairs and/or performance improvement representatives to monitor and ensure completion of required performance improvement activities and preparation of performance improvement reports; assures resolutions are implemented in a timely manner; assists the departments in the preparation of agendas, medical record reviews and focused reviews.
Participates in and performs medical record and focused peer review activities, including but not limited to areas such as Morbidity and Mortality Reviews.
Reviews, interprets and assists medical staff and hospital departments in the implementation of applicable regulatory and accreditation agencies' standards and regulations; directs the departments in activities to ensure compliance with applicable standards and regulations; ensures that the requirements of performance improvement are integrated with safety and risk management activities.
Prepares quality improvement statistical indicators, narrative reports and collateral materials; assists in the preparation of the program budget; maintains hospital-wide quality improvement activity records.
Assists the medical and nursing staff in development of treatment protocols and guidelines to improve the quality of care; participates in the development and preparation of materials for performance improvement/peer review processes related to medical staff credentialing.
Plans and conducts performance improvement in-service education and training programs to hospital medical staff, nursing staff and ancillary departments; provides training and direction for performance improvement teams to carry out activities; coordinates and participates in review activities.
Experience:Three years of progressively responsible experience as a registered nurse in a hospital, health plan or ambulatory clinic system, including one year of responsibility for quality improvement functions and activities, such as chart audits, data gathering and analysis, providing administrative support to peer review committees or functions, and preparing quality improvement summaries and reports.
Substitution:EITHER1) Possession of a bachelor’s degree in nursing, health science or closely related field; OR 2) Possession of a current Certified Professional in Healthcare Quality (CPHQ) certificate, may be substituted for one year of the required general nursing experience.
Licenses and Certificates: 1) Current registration as a nurse in the State of California; AND 2) possession of a valid California driver's license.
Theory, techniques, tools, and practices of quality assurance and performance improvement applicable to measure, assess and control quality of care provided by a health care agency; principles of the Nurse Practice Act and the nursing process; principles of documentation; basic supervision; safety principles and practices; applicable federal and state laws and regulatory and Joint Commission accreditation standards; information gathering techniques for resources, materials and other information applicable to quality assurance and performance improvement; data analysis; statistical methods and reporting techniques; basic computer operations, including software pertinent to department operations.
Plan, coordinate, implement and report on quality assurance activities; supervise and participate effectively in performance improvement processes; capture, analyze and report quality improvement data; communicate effectively, both orally and in writing with medical and professional staff, and others; follow oral and written instructions of a technical and professional nature; establish and maintain effective working relationships with medical and professional staff and others; establish and maintain effective customer service; maintain accurate records and prepare clear and concise reports; present data and information in a group setting; set priorities; work accurately under pressure; understand, interpret and apply state, federal and local regulations, medical standards, policies and procedures; teach quality improvement tools; develop basic teaching plans and teach classes; provide and promote a positive learning environment; utilize computers and office automation equipment.
Mobility – frequent operation of a data entry device; sitting for long periods; walking; occasional standing for long periods, pushing/pulling, bending/squatting; Frequency of Lifting – frequent lifting of 5 pounds or less; occasional lifting of 5 to 30 pounds; Visual Requirements – constant overall vision; frequent eye/hand coordination, reading/close-up work; occasional color perception, depth perception and field of vision/peripheral; Dexterity – occasional holding, reaching, grasping, repetitive motion, writing; Hearing/Talking – frequent hearing normal speech, hearing on the telephone, talking in person, talking on the telephone; occasional hearing faint sounds, talking over public address systems; Special Requirements– frequent public contact, decision making, concentration; present information in a group setting; occasional emergency situations; exposure to trauma, grief, death; working alone; overtime/travel; Environmental Conditions – occasional exposure to noise, dirt, dust, smoke, fumes, poor ventilation, variable weather conditions.