JOB SUMMARY:

In addition to the responsibilities listed above, this position is also responsible for providing consultation and education related to clinical quality and patient safety, accreditation, regulatory and licensing (AR&L), risk management, and infection prevention and control; evaluating, designing, developing, and implementing evidence-based guidelines, principles, and/or programs related to area of work as well as to reduce variation in clinical practice and optimize patient outcomes; collecting, analyzing, reporting, and presenting clinical data for a variety of users including for state, federal, and local agencies; facilitating education regarding the interpretation of compliance methods when preparing for regulatory reviews, the interpretation of regulatory requirements, and regional project goals; monitoring, reporting, and developing mitigation plans for all occurrences which may lead to medical center liability adjusting to remove barriers and/or issues, as necessary; supporting the medical centers continuous survey readiness program to maintain compliance with regulatory standards; and serving as a liaison with applicable government agencies, regulatory agencies, and other organizations.

MINIMUM QUALIFICATIONS:

• Minimum three (3) years of experience in a leadership role with or without direct reports.
• Minimum two (2) years of experience with databases and spreadsheets or continuous quality improvement (CQI) tools.
• Minimum four (4) years of experience in clinical setting, health care administration, or a directly related field.
• Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum six (6) years of experience in quality, performance improvement, or a directly related field OR Minimum nine (9) years of experience in quality, performance improvement, or a directly related field.
• Registered Nurse License (California)

ADDITIONAL REQUIREMENTS:

• Knowledge, Skills, and Abilities (KSAs): Clinical Quality Expertise; Negotiation; Business Process Improvement; Risk Management; Compliance Management; Health Care Compliance; Applied Data Analysis; Consulting; Development Planning; Agile Methodologies; Project Management; Risk Assessment; Health Care Quality Standards; Quality Improvement
  PrimaryLocation : California,Santa Clara,Santa Clara Hospital
  HoursPerWeek : 40
  Shift : Day
  Workdays : Mon, Tue, Wed, Thu, Fri
  WorkingHoursStart : 08:00 AM
  WorkingHoursEnd : 04:00 PM
  Job Schedule : Full-time
  Job Type : Standard
  Employee Status : Regular
  Employee Group/Union Affiliation : NUE-NCAL-09|NUE|Non Union Employee
  Job Level : Individual Contributor
  Job Category : Quality & Safety
  Department : Santa Clara Homestead Hospital - Hosp Admin-Quality Leadership - 0208
  Travel : No
  Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.
• Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.
• Develops and implements data collection and analyses to support quality improvement efforts by: conducting advanced statistical analysis for quality improvement evaluations, special projects, and other work for multidisciplinary review; investigating opportunities to improve the reporting and narrative summaries of improvements by integrating multiple utilization data reporting systems to develop and maintain a variety of statistical reports in a format which enables care providers to see variations in practice patterns; presenting quality improvement metric reports to demonstrate improvements and effectiveness of quality improvement programs to department and program managers; and serving as a technical expert to team members, supervisor, and key stakeholders by interpreting trends, potential errors, and other analyses, by assisting in problem resolution for data source analysis, and by advising on the application of results.
• Supports in-depth and advanced quality improvement and improvement risk management efforts by: researching corrective action plan for areas of improvement identified through utilization review, clinical records audit, claim denials, member satisfaction surveys, and auditing surveys for their cost effectiveness and impact on department functioning; ensuring process improvements are compliant with established internal and external regulation requirements at the local and state level; conducting complex root cause analysis, failure mode and effect analysis, and other assessments in response to significant events near misses, and good catches in order to identify areas of improvement and evaluate newly internalized processes and programs; and proactively escalating high-risk issues and trends to appropriate entity for resolutions.
• Investigates opportunities to develop new and improve current quality improvement performance metrics development, collection, and utilization by: researching and recommending best practices in the development of performance metrics, standards, and methods to establish improvement success; consulting with multiple stakeholders, often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical, meet multidisciplinary standards, and are approved at the department level; and designing the delivery of measurable results and alignment with strategic objectives by integrating metric utilization into workflows with sound methodology.
• Facilitates the development of quality improvement initiatives by: leveraging and implementing advanced technology, methods, and tools to develop stakeholders capabilities for process improvements; monitoring the use of data-driven improvement principles, tools, and problem-solving methods, including Lean/Six-Sigma concepts and techniques using quality improvement metrics; and synthesizes key information and works to break down issues into logical part for the creation of milestones, detailed workplans, and documentation practices in order to create a clear, logical, and realistic plan.
• Serves as the subject matter expert for quality improvement processes and regulations for internal and external stakeholders by: providing consultation independently on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees, projects to drive discussions on drawing guidelines on the enforcement, development of policies or procedures of regulations and auditing processes; fostering collaborative, results oriented partnerships to ensure compliance with regulations and improve patient safety, maintain the KP safety culture, reporting accuracy, and health outcomes and provides insight to the regulation climate; developing educational programs to raise awareness for changes in regulation requirement, internal concerns, and system/database usage; and anticipating issues and weighs practical and technical considerations in addressing issues and coordinates with the appropriate stakeholders to develop resolutions.
• Develops stakeholder development and quality performance review processes by: developing and improving the utilization and performance reviews processes by utilizing multidisciplinary criteria and guidelines, and takes a systematic approach to quality improvement; identifying performance areas of improvement for at the program, provides feedback and coaching as needed, and develops a corrective plan; presenting performance review reports at the program level to department managers; and developing the curriculum for training and educational programs related to process improvement for quality improvement programs.