Performance Improvement Coordinator (RN), Quality Services

ABOUT MARINHEALTH a UCSF Affiliate

Come and be a part of our healing team at the award-winning MarinHealth! Ranked in the top 3% of general hospitals in the country, we have made great strides since returning to our roots as an independent hospital. As Marin County’s only acute hospital and a vital resource for a wide range of essential health care services, it is our mission—and our passion—to excel in every medical specialty. We attract the finest physicians and employees who appreciate having the best of both worlds: the resources and medical sophistication of an academic medical center combined with the personalized, caring touch of an independent hospital. We have an exceptionally collaborative team that adheres to the highest service excellence standards to ensure that we deliver world-class, personalized care to patients. Our Joint-Commission accredited hospital has won numerous awards and certifications in delivering best-in-class health care in the San Francisco Bay Area.

WHAT WE OFFER

MarinHealth offers a generous suite of employee benefits, which includes a comprehensive and rich health benefits program (medical, dental, vision and prescription plans). Our robust Wellness @ Work program (e.g. onsite health & fitness classes, discounts, etc) also promotes a healthier lifestyle for employees and to support you on your Healthy Healer journey. Other benefits include, but are not limited to, a 403(b) contribution plan and company-funded retirement plan, life insurance, vacation, holiday and sick leave, which you will start accruing immediately. Our benefits are highly competitive and considered to be one of the best in the Bay Area! Find your healing place at MarinHealth.

External hires are subject to a background check and pre-employment medical screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with federal, state and local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classifications protected by federal, state & local laws.

JOB SUMMARY:

Under the general direction of the Executive Director, Quality Management Services provides leadership and organizational support for the clinical quality and outcomes program. Develops and recommends strategies and processes that result in measurable improvement in the delivery and outcomes of patient care through application of evidenced-based best practices and using current Performance Improvement methods/tools. Works collaboratively with medical staff, leadership, medical directors, nursing and other members of the healthcare team in researching, designing, and implementing “best practice” guidelines and protocols to support high quality services and continuous improvement in patient care outcomes. Serves as clinical quality and performance improvement liaison to MarinHealth Medical Network quality teams to ensure enterprise-wide approach to clinical quality.

JOB SPECIFICATIONS:

Bachelor of Science degree in Nursing or Masters Entry Program Nursing degree or related field required. Graduate degree preferred.

Five (5) or more years of progressive experience in an acute patient care setting (preferred). Previous Clinical Quality or Performance Improvement experience preferred.

• Recent experience in healthcare setting using performance improvement methodology with successful and actionable outcomes.
• Progressive knowledge of Joint Commission, State, Federal laws regarding Quality Management, Medical Staff support; participates in Joint Commission, State and Federal surveys and internal survey processes for using continuous readiness methodology.
• Knowledge of audit/study methodology and health statistics applicable to performance improvement
• Knowledge of concurrent and retrospective chart review
• Proficiency in epic-based electronic records navigation and information retrieval
• Knowledge of automated data information systems as applicable to hospital and medical staff activities
• Demonstrated clinical expertise to effectively facilitate evaluation of quality care
• Advanced skills in data management as well as the ability to collect, analyze, and present data to groups and individuals
• Provides necessary education and training to department staff, medical staff, and hospital staff as needed to ensure best practices are implemented, variances reduced, and clinical outcomes measured and improved
• Demonstrated ability to develop, organize, facilitate, and lead special projects
• Ability to work collaboratively with physicians, hospital staff, and external organizations
• Contributes to the collection, verification, and presentation of statistical data and information for practitioner reappointment profiles, Ongoing Professional Practice Evaluation, and assessments of clinical competence of practitioners through chart reviews and data analysis
• Establishes and maintains effective work practices; maintains high level of professional demeanor, competence, knowledge, integrity, and confidentiality; models the mission and vision of the organization in daily interactions and other related professional activities
• Supports sentinel event investigations, chart review, and process flow diagramming as directed.
• Demonstrated oral and written communication skills
• Intermediate computer skills in a Windows environment
• Ability and willingness to be cross-trained
• Ability to read, write, and follow English verbal and written instructions

LICENSE/REGISTRATION/CERTIFICATION:

Registered Nurse with current and active license preferred

Certified Professional in Healthcare Quality (C.P.H.Q.) preferred. If no certification, obtains certification within two years in program mutually agreed upon with Executive Director.

PRIMARY CUSTOMER SERVED (Age Specific Criteria):

This position is not a patient care position, and as such, this section does not apply

PATIENT PRIVACY (HIPAA Compliance):

Employees in this position have access to protected health information. The protected health information a person in this position can access includes demographics, date of service, insurance/billing, medical record summary information, and all other information that may be contained in patient records. This position requires patient health information to perform the functions outlined as part of this position description.

ESSENTIAL (not modifiable)

• Facilitate and support clinical quality performance improvement (PI) throughout the organization by collaborating with others, managing multiple deadlines, making independent decisions and prioritizing to achieve agreed upon deadlines.
• Serves as Quality staff to house-wide performance improvement initiatives such as Sepsis, Throughput, Readmissions committees.
• Review core measures data, validate medical records abstractions completed by vendors in support of core measures to ensure accurate and complete data submissions for external quality organizations.
• Identify metrics appropriate to clinical quality PI project and scope, facilitates, collects and analyzes appropriate data as needed in support of clinical quality.
• Facilitates group process in using PDSA cycles and quality methods/tools to achieve goals.
• Provides necessary education and training to department staff, medical staff, and hospital staff as needed to ensure best practices are implemented, variances reduced, and clinical outcomes measured and improved.
• Maintains current knowledge base of regulatory agencies standards, and analyzes and synthesizes content of standards, communicating the intent to appropriate constituents.
• Support external quality organization reporting and periodic reviews and surveys.
• Performs tasks pertinent to the Quality Improvement Program for the Medical Staff
• Advances patient safety culture through application of patient safety concepts in performance improvement processes where relevant.
• Facilitates the development of performance improvement capacity in MHMN as directed.
• Performs tasks pertinent to the implementation of evidence-based practice across the organization.

SECONDARY (modifiable)

Special projects and all other duties as assigned

At MarinHealth, our top priority is the well-being of our employees, patients, and community. As such, we require all employees to receive necessary immunizations, including the measles, mumps, varicella, and seasonal flu vaccinations as a condition of employment and annually thereafter. Additionally, the continued recommendation to obtain a COVID booster vaccination status. We understand that some individuals may require medical or religious exemptions from these requirements, but we remain committed to prioritizing the health and safety of all. Thank you for helping us in our efforts to maintain a healthy and safe environment for all.

The compensation for this role listed on this posting is in compliance with applicable law. The selected candidate’s compensation will be determined based on the individual’s skills, experience, internal/market equity factors, and qualifications. This posted minimum and maximum range represents the minimum and maximum of what we reasonably expect to compensate for the position. Furthermore, all compensation decisions are ultimately determined in accordance with our compensation philosophy. Compensation for positions covered by collective bargaining agreements are governed by the agreements in the aforementioned document.

Additional Information

• Department: 8750 - Quality Management
• Job Schedule: Full Time - 40 hours/week
• Job Shift: Day
• Hours per Two-Week Period: 80
• Shift Hours: 8 Hour Shift
• Job Number: 13153 - TBD

Job Types: Full-time, Permanent

Pay: $69.33 - $103.99 per hour

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Retirement plan
• Vision insurance

Standard shift:

• Day shift

Weekly schedule:

• 5x8

Experience:

• Performance Improvement or Quality Improvement: 1 year (Preferred)

Work Location: In person