Quality Improvement Healthcare Specialist 4

Job Function Summary

Involves the establishment and supervision of processes (e.g., performance improvement, clinical documentation, etc.) to achieve the optimal degree of excellence in the services rendered to every patient. Evaluation of practice operates within the parameters of patient outcome, cost-benefit in care provision, and patient access to the health care delivery system. Provides for internal strategic planning efforts and implementing continuous quality improvement programs.

Generic Scope

Technical leader with a high degree of knowledge in the overall field and recognized expertise in specific areas; problem-solving frequently requires analysis of unique issues / problems without precedent and / or structure. May manage programs that include formulating strategies and administering policies, processes, and resources; functions with a high degree of autonomy.

Custom Scope

Applies extensive knowledge of quality data analysis and / or improvement (QI) concepts, methodologies, and data collection and abstraction techniques to substantial projects of large scope and high degrees of complexity.

The Quality Improvement (QI) Specialist is responsible for leading and supporting service line and clinical outcomes-based improvement work within the UCSF Benioff Children’s Hospitals (BCH) in Oakland and San Francisco Emergency Departments (ED). The QI Specialist partners closely with physicians, nurses, and administrative leadership to monitor, evaluate, and improve quality and safety, which includes: the development of short and long-term quality and safety goals; managing a portfolio of quality and safety initiatives; conducting complex analyses of data from multiple sources; and contributing to the education and development of faculty and staff in Quality Improvement methodologies.

This role provides technical expertise and leadership in Quality and Safety, supports and augments the collaborative work of physician and nursing leadership in Quality and Safety and, in this partnership, sustains and improves the foundation of quality and safety performance.

The QI Specialist applies extensive knowledge of quality data analysis, improvement concepts and methodologies, and data collection and abstraction techniques to lead and support projects of substantial scope and complexity. The QI Specialist will be involved in all aspects of quality improvement and safety projects, including the assessment, planning, improvement, and maintenance phases.

This requires extensive knowledge, skills, and abilities to evaluate processes and outcomes using qualitative and quantitative data and effective analytical methods such as statistical process control (SPC). It also requires excellent communication skills with clinical and non-clinical stakeholder groups, and the ability to develop collateral—tools, documents, sustainability data methods, presentations, etc.—that enable the success of the work.

The QI Specialist must also be a positive driver of the culture of safety and continuous improvement and hold others accountable for their role in improving quality performance. The QI Specialist will be an integral part of a team working to enhance the care we provide for our pediatric ED patients.

Department Overview

The Department of Emergency Medicine (DEM) provides emergency medical care to over 177,000 patients annually at the UCSF Medical Center at Parnassus, UCSF Benioff Children’s Hospitals at Mission Bay and Oakland and Zuckerberg San Francisco General Hospital and Trauma Center.

DEM administrative and research staff support the work of 90+ full-time faculty and 50+ part-time attending physicians, a residency program, fellowship programs, and over 300 housestaff and students each year.

Our vision is to be the leader in compassionate, innovative and equitable emergency care for all people at all times.

Required Qualifications

• Minimum 5 years of related experience.
• In-depth knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.
• In-depth knowledge of QI models, tools, and techniques, including collection, abstraction, validation, analysis, reporting of data, and use of performance and benchmark indicators.
• Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see projects through from inception to completion on schedule.
• Advanced critical thinking and problem solving skills to manage multiple levels of highly-complex information and responsibilities, to quickly assess problems, and to develop and implement timely and effective solutions.
• Advanced interpersonal skills for collaborating effectively with all levels of clinical and technical staff and representatives of external regulatory agencies and for mentoring lower-level QI staff.
• Advanced ability to effectively convey complex clinical, technical, and educational information both verbally and in writing, and to produce high quality reports, documentation, and presentations.
• Advanced knowledge of various administrative and business software packages, and of the specialized applications for quality data management.
• Advanced skills to influence and persuade staff, management, and clinicians at all levels and across departments.

Required Education

• Bachelor's degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience.

Preferred Education

• Master’s degree in public health, healthcare administration, business, or related area, and / or equivalent combination of experience / training.

Preferred License

• Registered Nurse.

Preferred Certifications

• Certified by a reputable organization in QI, Process Improvement, or Lean (CPHQ, IHI IA, Lean Six Sigma Belt, etc.).

Quality Improvement Data Management and Performance Measurement

Supports clinical areas on data management activities and projects with significant clinical complexity and organizational scope. Develops relevant department and service quality indicators, structures and measures.

• Leads the oversight, analysis, and strategic use of division-level Quality Improvement (QI) data to inform decision-making, identify performance gaps, and drive measurable improvements in clinical quality and safety.
• Responsible for understanding and ownership of the division’s QI data.
• Builds and maintains outcomes data with QI Macros.
• Constructs and validates datasets with oversight from RN/MD process owners/QS directors as applicable.
• Researches best practices and develops and implements improvements in the data collection and reporting processes and / or systems.

Complex Data Analysis, Reporting and Clinical Quality Review

Analyzes and interprets highly complex data of broad scope, and summarizes statistical findings. Develops corresponding reports, dashboards, presentations, and action plans. Prepares and delivers executive summaries.

• Develops SPC charts and other QI methodology visualizations.
• Identifies statistical trends, problems, and potential issues in patient care and services.
• Participates in or leads project teams in clinical departments to investigate, develop, and implement corrective plans, and monitor their effectiveness.
• Prepares incident reports and conducts QI reviews of highly-complex mortality cases, sentinel events, readmissions, and other cases flagged by screening criteria.
• Identifies cases that require urgent reviews and collaborates with management as required to develop and implement appropriate responses.

Quality Improvement Project Leadership

Participates in or leads clinical and technical teams on broad-scope projects using advanced QI models to develop new plans, criteria, and benchmarks.

• Project-manages new QI initiatives as assigned and provides hands-on support for all division QI projects, including those led by physician leaders.
• Independently walks a project through a full QI methodologic approach (A3, etc.).
• Owns the QI process from problem definition through PDSA cycles and sustainment planning, with minimal input from the QI Directors.
• Reduces bottlenecks on existing initiatives where applicable.
• Serves as a technical leader to provide advice and counsel others on highly-complex QI issues of functionality, efficiency, performance improvement, and program development.

Other Duties

• Other duties as assigned.

Budgeted Job Salary Range: will work with TA to ensure salary is equitable