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Eureka , CA, USA | Providence Saint Joseph Medical Center

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    Quality Assurance
  • Experience:
    5-7 years
    7-10 years
Job Description:
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Reporting to the Regional Chief Quality Officer, the Area Director of Clinical Quality, Patient Safety and Clinical Excellence is responsible for guiding, building and leading the hospital's quality, risk, patient safety and Performance Improvement (PI) program to support the Hospital's business objectives. Key focuses for this position include:

  • Building clinical quality, patient safety programs that improve the patient experience, quality outcomes and prioritize the safety of all patients, families and visitors who seek our services, and identify and reduce risk at St. Joseph Health ministries in the county.

  • Maximizing performance and external awareness of St. Joseph Health ministries outcomes and excellence, and,

  • Internal facilitation to achieve and sustain best practice for best benchmark performance.

The position plans, organizes and directs all aspects of the quality, risk, patient safety and performance improvement functions including clinical outcomes, patient safety, environment of care safety, infection control, risk management, operational improvements, service quality and organizational regulatory and accreditation readiness. The Director in collaboration with other members of the department provides the organization with focus and education on performance improvement, outcomes reporting, and regulatory issues.


  • Plans and manages implementation of all quality related initiatives that reduce risk, improve patient safety and overall quality outcomes for patients being served in Sonoma County.

  • Establishes a quality plan and review procedure annually that creates transparency from bedside to board.

  • Establishes a patient safety program consistent with Providence high-reliability organization approach that is implemented and consistently sustained by leadership.

  • Routinely reviews risk issues and identifies opportunities to implement change that reduces overall clinical and organizational risk.

  • Assures compliance with regulatory and accreditation standards and integrates multiple requirements into performance improvements plans and initiatives.

  • Aligns and supports team with infection prevention priorities and intervention to assure patient safety overall.

  • Act as an agent on behalf of the best interests of the healthcare consumer; works to address special needs (e.g., disparities in care, health literacy, and patient safety), values and works to provide support and resources as needed.

  • Analytic thinking and knowledge-based decision making: assesses multiple sources of data and information, identifies key interventions that address multiple needs, breaks problems down into parts or steps; (workflow) recognizes multiple layers of cause and effect; collects appropriate information to make decisions informed by available evidenced competencies and patient experiences and perspectives; values and supports transparency and works with a team based environment to sustainably implement change.

  • Development of a knowledge-rich environment—supports continuous improvement/learning and transparency using the data available to support decision making (collection, record keeping, access) by using emerging technology and methods.

  • Helps position the Providence St. Joseph Health System, Sonoma County as the premiere hospital system in Sonoma County relative to key clinical/patient safety and patient experience outcomes. Examples of activities would include the development of clinical pathways with medical and hospital staff, benchmarking, participation in multi-hospital collaborative, and standardization of care to support Care Redesign and CPOE adoption and implementation for best documentation and ease of use.

  • Able to balance competing priorities and balance clinical, operational and financial goals. Able to make a business case for changes in process or product in collaboration with other disciplines so that mutual goals are met or potential consequences for changes requested by Quality and Patient safety are weighed and mitigated in advance.

  • PI Program management must include ability to rapidly respond to shifts in regulatory and accreditation requirements or emerging science through a nimble adaptive management style. Performance Improvement (PI) – encompasses clinical outcomes, patient safety, environment of care safety, infection control, risk management, operational improvements, service quality and organizational regulatory and accreditation readiness.

  • Considers the ethical implications of decisions; acts openly and transparently; develops a reputation as trustworthy/reliable.

  • Ensures integration of the Hospital’s quality, financial, operational and strategic planning processes to facilitate house-wide focus and achievement of performance improvement priorities.

  • Fosters a climate that facilitates clear, fast, open and accurate communication regarding Performance Improvement (PI) and outcomes at all levels of the organization, with the Board of Trustees, Medical Staffs, and with the communities we serve.

  • Champions an organizational environment of education, learning, and organizational competencies at all levels using proven principles and tools for continuous assessment and achievement of Performance Improvement tactics and clinical outcomes.

  • Assures that major decisions related to Performance Improvement and Clinical Quality takes into account their effect on the organization and the communities we serve.

  • Establishes mutually beneficial partnerships with external consumers (payors, brokers, medical groups, employer groups and other community and patient group contacts) to maximize their awareness of Performance Improvement and Clinical Outcomes activities for the St. Joseph Health System in Sonoma County.

  • Facilitates internal and external stakeholder dialogue related to their quality projects and needs.

  • Establishes systems and resources that enable cross-functional analysis, internal and external benchmarking, and complex problem-solving across organizational boundaries.

  • Collaborates with leaders and staff across the organization, and with other entities and the System office, in pursuit of best practice and effective communication of excellent outcomes to our community.

  • Focus on supporting medical staff quality and peer review procedures to include OPPE.

  • Responsible for the deployment of quality and patient safety reward and recognition.

  • Ensures that staff possesses the appropriate knowledge and skills necessary to provide care and performance improvement appropriate to the age of the patients served.

  • Ensures that staff is competent in assessing and interpreting age appropriate data about the patient’s status in order to identify age-specific needs and provide the care needed.


Required experience/education for this position include:

  • Bachelor's degree in Nursing

  • Master's Degree in clinical field (e.g. Nursing or similar/equivalent)

  • California nursing license

  • Training in performance improvement tools and techniques

  • Training in change management, team dynamics and facilitation

  • 10 or more years in Performance Improvement

  • 5 years of increasing responsibility in leadership/oversight of quality programs

  • Proficiency in knowledge of data management, data governance and clinical analytics (internal and external) as well as data presentation

  • Proficient in Microsoft Office

  • Excellent organizational skills especially when coordinating big projects, committees and special events

  • Idea champion and effective change agent

  • Strong interpersonal skills to work with all levels of employees, physicians and customers

  • Ability to create strong business partnerships

  • Strong facilitation and complex problem-solving skills

  • Ability to maximize output to multiple deadlines, while maintaining a calm demeanor

  • Demonstrated excellent verbal, written and presentation communication skills

  • Expert knowledge of applicable accreditation and regulatory standards.

Preferred experience/education for this position include:

  • Doctorate in clinical field (e.g. PharmD or equivalent)

  • Experience with system initiatives or multi-hospital performance improvement collaborative

  • National certification in performance improvement (eg. Lean six sigma, green or black belt and Certified Professional in Healthcare Quality-CPHQ).

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