Santa Clara County
Quality Improvement Coordinator
Santa Clara County, San Jose, California, United States, 95123
Under direction, to plan, coordinate, and implement quality improvement activities as required by various regulatory bodies, such as State, Federal, and The Joint Commission (TJC) regulations and requirements for the County of Santa Clara Health System (CSCHS).
Increase your chances of reaching the interview stage by reading the complete job description and applying promptly.
The Power of WE : Together, we can make a greater impact. Bringing better care and expanding healthcare services across the community.
Santa Clara Valley Healthcare (SCVH) is the second largest public health care system in California and includes three acute care hospitals, 14 clinics and 60+ specialty and sub-specialty services. Our mission is to provide high-quality, accessible healthcare and excellent service to everyone in Santa Clara County.
Santa Clara Valley Medical Center
- SCVMC is a full-service tertiary acute care teaching hospital with 699 licensed beds providing a wide range of specialized services, including Rehabilitation, Burn, Trauma, and NICU. SCVMC was ranked by U.S. News and World Report as #6 Rehabilitation Hospital in the nation and #1 in the West and designated as a 2024 High Performing hospital for Maternity Care, Heart Failure, Stroke, Hip Fracture, and Pneumonia.
O'Connor Hospital
- O'Connor Hospital (OCH) is a 358 licensed bed acute care facility offering a full range of inpatient and outpatient medical, surgical and specialty programs to residents of Santa Clara County. It was founded in 1889 as one of the first hospitals in the county. OCH has grown significantly over the past five years in both its inpatient volume and its Emergency Department visits. Along with these volume increases other ancillary and clinical departments like imaging, lab, pharmacy, and respiratory have seen growth as well.
St. Louise Regional Hospital
- Since 1989, St. Louise Regional Hospital (SLRH) has been caring for the residents in Santa Clara and San Benito Counties, offering a wide range of inpatient and outpatient medical specialties. SLRH has 93 beds, is a Designated Primary Stroke Center, and is the only acute care hospital in the area. Located in Gilroy, SLRH maintains a CALSTAR 2 emergency helicopter base on the premises.
Regional Medical Cente r – Regional Medical Center (RMC) is a 258-bed hospital that is the main emergency healthcare provider for East San José, treating a wide range of critical and life-threatening conditions for more than 60 years. Since the SCVH integration of RMC effective 4/1/25, RMC has expanded the critical services including Level II trauma, Thrombectomy capable Stroke Center and STEMI care, and has been seeing an increased number of emergency visits and inpatient volume. The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Each individual in the classification does not necessarily perform all duties listed. Monitors the County of Santa Clara Health System departments to ensure compliance with the Quality Improvement Plan; Coordinates division and department quality improvement activities, including surveys and audits; Ensures that standards, policies, and procedures are consistent with professional standards and requirements as defined by various regulatory bodies; Assesses quality improvement training needs; plans, implements, and/or coordinates training for staff; Participates in organizational and departmental committees and task forces; Participates in developing systems and procedures to meet the internal goals and objectives of the Quality Improvement Plan; Conducts and supports investigations with medical, nursing, and other staff; plans quality improvement activities to resolve identified problem areas; Maintains current knowledge of organizational goals and objectives; Promotes and facilitates process/quality improvement activities within the Health System; Collaborates with various stakeholders regarding organizational standards, policies, and procedures; Initiates changes in standards, policies, procedures, and practices based on quality improvement review; Interprets policies and regulations to medical, nursing, and professional support staff; Promotes compliance with legal and regulatory requirements; Plans accreditation and regulatory surveys; prepares responses/reports based on reports of findings; Works to mitigate organizational and patient safety risks and collaborates with Risk Management staff regarding risk/quality issues; Identifies local and national trends applicable to quality improvement standards; Evaluates the feasibility of new programs to enhance compliance with standards; Acts as a resource for quality improvement activities; Performs concurrent and retrospective chart reviews and analysis for selected department and organizational indicators; Collaborates with staff from medicine, nursing, and other professional support staff in the development, implementation, and evaluation of Patient Care Guidelines; may collaborate with medical staff for peer review and quality support, when indicated; Initiates and participates in research related to standards, quality improvement, and risk management; utilizes research to support changes of standards and practice; May be assigned as a Disaster Service Worker (DSW), as required*; Performs other related duties, as required. Training and Experience Note : The required knowledge and abilities are attained through four (4) years of full-time Registered Nursing (RN) experience in an accredited hospital, clinic, and/or healthcare setting. Nursing management experience is desirable but not required. Special Requirements Possess and maintain an active California Registered Nurse license, without restrictions, for the duration of employment in this classification. Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization. *As a condition of employment, pursuant to California Government Code Sections 3100-3109 and Local Ordinance, all County of Santa Clara employees are designated Disaster Service Workers (DSWs), including extra help. A DSW is required to complete all assigned DSW-related training, and in the event of an emergency, return to work as ordered. Knowledge of : Hospital, outpatient, or location-specific healthcare organizations, operations, and procedures; Federal and State healthcare laws and regulations common to the operation of hospitals in California and/or laws applicable to the healthcare setting; Regulations of intermediary agencies pertaining to hospital stay coverage (e.g., Medicare and MediCal); Quality improvement and risk management standards, policy, procedures, and protocols; Current trends, issues, and research in Quality Improvement in large medical services systems; Standards, policies, procedures, and medical protocols in a healthcare setting; The Joint Commission standards and Title XXII requirements and Federal regulations; Regulatory requirements for acute care hospital, ambulatory, or applicable healthcare settings; Medical terminology and related levels of care and treatment; Methods, regulations, and procedures for research within a healthcare setting; Evaluation and assessment techniques; Record keeping and reporting procedures; English usage, style, grammar, punctuation, and spelling; Common computer systems and applications. Ability to : Analyze data, write reports, identify trends and appropriate corrective action plans, and evaluate improvement programs and activities; Evaluate and interpret complex medical regimens pertaining to quality-of-care standards; Plan, develop, and organize work; Communicate effectively, both orally and in writing, with people of diverse backgrounds and cultures; Develop personal and professional quality improvement goals; Facilitate quality improvement teams to implement quality improvement goals and standards; Work effectively and manage multiple projects with minimal supervision; Manage multiple conflicting priorities while demonstrating strong organizational and leadership skills; Plan and implement quality improvement educational activities for medical, nursing, and professional support staff; Maintain current knowledge of trends/practices in quality management; Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and representatives of other agencies.
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Increase your chances of reaching the interview stage by reading the complete job description and applying promptly.
The Power of WE : Together, we can make a greater impact. Bringing better care and expanding healthcare services across the community.
Santa Clara Valley Healthcare (SCVH) is the second largest public health care system in California and includes three acute care hospitals, 14 clinics and 60+ specialty and sub-specialty services. Our mission is to provide high-quality, accessible healthcare and excellent service to everyone in Santa Clara County.
Santa Clara Valley Medical Center
- SCVMC is a full-service tertiary acute care teaching hospital with 699 licensed beds providing a wide range of specialized services, including Rehabilitation, Burn, Trauma, and NICU. SCVMC was ranked by U.S. News and World Report as #6 Rehabilitation Hospital in the nation and #1 in the West and designated as a 2024 High Performing hospital for Maternity Care, Heart Failure, Stroke, Hip Fracture, and Pneumonia.
O'Connor Hospital
- O'Connor Hospital (OCH) is a 358 licensed bed acute care facility offering a full range of inpatient and outpatient medical, surgical and specialty programs to residents of Santa Clara County. It was founded in 1889 as one of the first hospitals in the county. OCH has grown significantly over the past five years in both its inpatient volume and its Emergency Department visits. Along with these volume increases other ancillary and clinical departments like imaging, lab, pharmacy, and respiratory have seen growth as well.
St. Louise Regional Hospital
- Since 1989, St. Louise Regional Hospital (SLRH) has been caring for the residents in Santa Clara and San Benito Counties, offering a wide range of inpatient and outpatient medical specialties. SLRH has 93 beds, is a Designated Primary Stroke Center, and is the only acute care hospital in the area. Located in Gilroy, SLRH maintains a CALSTAR 2 emergency helicopter base on the premises.
Regional Medical Cente r – Regional Medical Center (RMC) is a 258-bed hospital that is the main emergency healthcare provider for East San José, treating a wide range of critical and life-threatening conditions for more than 60 years. Since the SCVH integration of RMC effective 4/1/25, RMC has expanded the critical services including Level II trauma, Thrombectomy capable Stroke Center and STEMI care, and has been seeing an increased number of emergency visits and inpatient volume. The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Each individual in the classification does not necessarily perform all duties listed. Monitors the County of Santa Clara Health System departments to ensure compliance with the Quality Improvement Plan; Coordinates division and department quality improvement activities, including surveys and audits; Ensures that standards, policies, and procedures are consistent with professional standards and requirements as defined by various regulatory bodies; Assesses quality improvement training needs; plans, implements, and/or coordinates training for staff; Participates in organizational and departmental committees and task forces; Participates in developing systems and procedures to meet the internal goals and objectives of the Quality Improvement Plan; Conducts and supports investigations with medical, nursing, and other staff; plans quality improvement activities to resolve identified problem areas; Maintains current knowledge of organizational goals and objectives; Promotes and facilitates process/quality improvement activities within the Health System; Collaborates with various stakeholders regarding organizational standards, policies, and procedures; Initiates changes in standards, policies, procedures, and practices based on quality improvement review; Interprets policies and regulations to medical, nursing, and professional support staff; Promotes compliance with legal and regulatory requirements; Plans accreditation and regulatory surveys; prepares responses/reports based on reports of findings; Works to mitigate organizational and patient safety risks and collaborates with Risk Management staff regarding risk/quality issues; Identifies local and national trends applicable to quality improvement standards; Evaluates the feasibility of new programs to enhance compliance with standards; Acts as a resource for quality improvement activities; Performs concurrent and retrospective chart reviews and analysis for selected department and organizational indicators; Collaborates with staff from medicine, nursing, and other professional support staff in the development, implementation, and evaluation of Patient Care Guidelines; may collaborate with medical staff for peer review and quality support, when indicated; Initiates and participates in research related to standards, quality improvement, and risk management; utilizes research to support changes of standards and practice; May be assigned as a Disaster Service Worker (DSW), as required*; Performs other related duties, as required. Training and Experience Note : The required knowledge and abilities are attained through four (4) years of full-time Registered Nursing (RN) experience in an accredited hospital, clinic, and/or healthcare setting. Nursing management experience is desirable but not required. Special Requirements Possess and maintain an active California Registered Nurse license, without restrictions, for the duration of employment in this classification. Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization. *As a condition of employment, pursuant to California Government Code Sections 3100-3109 and Local Ordinance, all County of Santa Clara employees are designated Disaster Service Workers (DSWs), including extra help. A DSW is required to complete all assigned DSW-related training, and in the event of an emergency, return to work as ordered. Knowledge of : Hospital, outpatient, or location-specific healthcare organizations, operations, and procedures; Federal and State healthcare laws and regulations common to the operation of hospitals in California and/or laws applicable to the healthcare setting; Regulations of intermediary agencies pertaining to hospital stay coverage (e.g., Medicare and MediCal); Quality improvement and risk management standards, policy, procedures, and protocols; Current trends, issues, and research in Quality Improvement in large medical services systems; Standards, policies, procedures, and medical protocols in a healthcare setting; The Joint Commission standards and Title XXII requirements and Federal regulations; Regulatory requirements for acute care hospital, ambulatory, or applicable healthcare settings; Medical terminology and related levels of care and treatment; Methods, regulations, and procedures for research within a healthcare setting; Evaluation and assessment techniques; Record keeping and reporting procedures; English usage, style, grammar, punctuation, and spelling; Common computer systems and applications. Ability to : Analyze data, write reports, identify trends and appropriate corrective action plans, and evaluate improvement programs and activities; Evaluate and interpret complex medical regimens pertaining to quality-of-care standards; Plan, develop, and organize work; Communicate effectively, both orally and in writing, with people of diverse backgrounds and cultures; Develop personal and professional quality improvement goals; Facilitate quality improvement teams to implement quality improvement goals and standards; Work effectively and manage multiple projects with minimal supervision; Manage multiple conflicting priorities while demonstrating strong organizational and leadership skills; Plan and implement quality improvement educational activities for medical, nursing, and professional support staff; Maintain current knowledge of trends/practices in quality management; Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and representatives of other agencies.
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