BASIC FUNCTIONS:
Under the supervision of the Chief Quality and Informatics Officer, the primary role of the Joint Commission QI
Coordinator will be to ensure Joint Commission compliance by providing training & support to all VHT facilities.
This position is responsible for ongoing monitoring and assessment of key quality indicators for Joint Commission
readiness. The coordinator will assist the facilities towards process improvements that will support the reduction of
health care errors and other factors that contribute to unintended adverse patient outcomes.
DUTIES AND RESPONSIBILITIES:
1. Acts as Subject Matter Expert on The Joint Commission (TJC) standards and VHT’s practices, policies and
procedures developed to meet standards.
2. Maintains expert competence in accreditation and regulatory standards. Communicates relevant changes to
appropriate leaders and staff.
3. Provides in-service training to all staff in the area of TJC standards.
4. Coordinates the planning and execution of TJC Annual Period Performance Review.
5. Continually assesses and reports on “Joint Commission readiness”. In collaboration with leadership, coordinate
tracking and reporting of internal quality measures and follow-up of corrective actions plans.
- Utilizes records of past reviews, surveys and tracer activities to develop action plan
- Compiles and distributes compliance reports including appropriate action plans
- Develops P&P’s to comply with TJC standards and VHT’s practices
6. On a regular basis, required to work at any VHT facility.
7. Maintains professional knowledge by attending educational workshops, reviewing professional publications, and
materials on TJC standards and guidelines.
8. Creates and implements tools (training materials/guideline materials, P&Ps) designed to assess TJC
effectiveness throughout the organization.
9. Participate in periodic (CQI/Safety/Infection Control etc..) meetings established by VHT.
10. Works cooperatively with all staff members and outside sources in a professional manner to deliver a high level
of service.
11. Observe and practice all VHT Patient Experience Service Standards as outlined in “World Class Practices: My
Commitment to Care (which I have read and signed). Practice CICARE when interacting with patients, their
families, visitor, or internal customers.
12. Practice CICARE phone etiquette during all phone interactions.
13. Serve and protect the practice by adhering to professional standards, policies and procedures, federal, state, and
local requirements, and TJC Accreditation of Healthcare Organization standards. In addition to applicable
regulations such as: OSHA, HIPAA, and CLIA.
14. Perform other related duties, which may be inclusive, but not listed in the job description.
MINIMUM QUALIFICATIONS:
1. High School Diploma or GED
2. Minimum 2 years of experience in a clinical healthcare setting (preferable in a lead role)
3. Experience with The Joint Commission (outpatient) standards & guidelines
Job Description: Joint Commission Quality Improvement Coordinator, Page 2
4. Certification in Infection Prevention Control (or working towards certification)
5. Exceptional organizational and attention to details skills
6. Experience with industry recognized process improvement techniques
7. Excellent oral and written communication skills – be able to provide information in a clear and concise manner;
good interpersonal skills
8. Must have the ability to work both, independently and as a team member, to improve delivery of care to
PowerPoint
9. Sound judgment and initiative
10. Problem identification and solution skills
11. Experience of i2i Tracks and NextGen software highly preferred
12. Maintain and enforce the highest level of quality standards and customer services
13. Must have excellent public speaking and presentation skills – needs to be comfortable to present for a wide
variety of audiences
14. Ability to be flexible with work schedule and available to work at all site locations
15. Must have own transportation, valid California Driver’s License and current proof of automobile insurance
coverage
16. Demonstrated ability to provide world-class patient experience using CICARE principles and practices. Ability
to be proactive and to go above and beyond the call of duty; take initiative to provide a world class patient
experience in all encounters via email, phone or in person
TYPICAL WORKING CONDITIONS: The office setting is a normal work environment. Occasionally work
during early morning, evening or weekend. May be subjected to temperature variances in the office.
TYPICAL PHYSICAL DEMANDS: Requires sitting, standing, or walking for up to eight hours a day. Some
bending, stretching, or reaching may be necessary. Lifting up to 40 pounds may be required on occasion. Vision
must be correctable to 20/20 and hearing must be in the normal range for telephone contact.
WORK ENVIRONMENT: The work environment characteristics described here are representative of those an
employee encounters while performing the essential functions of this job. Reasonable accommodations may be
made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee may come in contact with hazardous equipment such as liquid
nitrogen, cleaning agents, and sharps. The noise level in the work environment is usually moderate but may become
excessively loud with the increased patient flow during a busy clinic day.
I, the employee, understand the responsibilities and standards of my position as listed above, and I agree to fulfill
them to the best of my ability. I understand I am an at-will employee and can be terminated at any time with or
without cause. I also understand the Valley Health Team Inc. will not be responsible in any manner for termination’s
which are due to defunding of Federal or State Contracts. I also agree that the VHT Board of Directors have the
right to modify the Personnel Policies which govern my employment at any time.
This organization is an Equal Opportunity Employer. It is our policy to comply with all applicable state and federal
laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification.

Job Type: Full-time

Pay: $22.60 - $29.48 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Experience:

• NextGen: 1 year (Preferred)
• Process improvement: 1 year (Preferred)
• i2i tracks: 1 year (Preferred)
• Compliance management: 2 years (Required)

Language:

• Spanish (Preferred)

License/Certification:

• Infection Prevention Control Certification or in progress (Required)
• California Driver’s License and automobile insurance (Required)

Work Location: In person