Sr Quality Improvement Specialist

We are seeking a dedicated and highly organized Sr. Quality Improvement Specialist to oversee the strategic planning, implementation, and continuous monitoring of UCSF Health’s programs designed to meet UCSF’s affiliate quality strategy, and achieve organizational objectives related to regulatory and alternative payment programs. The ideal candidate will engage closely with interdisciplinary teams and stakeholders, fostering a culture of transparency, teamwork, and innovation to ensure the seamless delivery of impactful programs.

Reporting to the Chief Quality Officer, the Sr. Quality Improvement Specialist is responsible for activities at UCSF Health that support the Mission, Vision, Goals and Values of the organization and promote high-quality patient and family care services across a growing provider network. The Sr. Quality Improvement Specialist is able to work independently and in collaboration with technical analysts and leaders across UCSF Health IT, Network Strategy, and Quality & Patient Safety teams, as well as other medical center staff and physician leaders to identify/implement strategies to improve the quality of care to patients of UCSF Health & the Affiliate Network.

In support of internal and external quality initiatives, the Sr. Quality Improvement Specialist applies extensive knowledge of quality data analysis and/or improvement concepts, EHR reporting methodologies, and data collection and abstraction techniques to substantial projects of large scope and high degrees of complexity.

In support of designated clinical departments, the incumbent will partner with physicians in a team-based approach to drive the program and maintain an open dialogue to achieve identified goals and priorities related to quality and safety. The Sr. Quality Improvement Specialist identifies potential problems in the care delivery process as a result of data monitoring and formulates a workgroup to resolve the issue and ensures new processes are in place to improve the delivery of care.

The portfolio of work assigned to the Sr. Quality Improvement Specialist includes the following areas:

Affiliate Quality Management

Direct annual goal setting and performance and related implementation with data teams and clinical domains

Clinical leader who can guide development and collaboration on shared clinical protocols and patient safety & quality activities across UCSF’s Affiliate Network

Serve as subject matter expert on clinical quality metric and reporting capabilities, partnering with colleagues from APeX Training, Healthy Planet & Ambulatory Clinical Resources Team on development and dissemination of workflow training tools

Establish collaborative relationships with partners based on trust, integrity, and transparency. On-site presence and ability to do joint clinic visits along with CIN Program Manager at least quarterly

Coordinate and support implementation of UCSF’s standard operating model for affiliate quality support, and partner with technical analysts to deliver standard deliverables as needed

Facilitate and lead stakeholder workgroups in alignment with strategic priorities and under direction of Network & Quality executive leaders

Supports the UCSF Network implementation of UCSF’s organizational strategy for optimizing value-based care and quality performance

Support mandatory quality reporting administration as needed; guide access to reports for leadership and physicians regarding program status, performance metrics, and opportunities for improvement.

Analyze performance data and trends, identifying areas of improvement and developing corrective action plans. Develop summaries and materials as needed to support strategic planning and decision-making.

OTHER FUNCTIONS AND RESPONSIBILITIES

The Sr. Quality Improvement Specialist may be expected onsite 5 days per week unless specified otherwise through an annual telework agreement. The role requires travel to practice locations throughout San Francisco as needed. The incumbent should be able to provide a safe and private home office environment for conducting UCSF business.

DUTIES & ESSENTIAL JOB FUNCTIONS

Identify the functions or tasks that employees in the job perform. The essential functions should state the purpose of the work and the results to be accomplished, rather than how the function is performed. Of the tasks listed, what percentage of time is devoted to each? The more time employees spend on a function, the more likely it is that the function is essential. Generally, include those functions that account for 10% or more of the work, i.e., key items that contribute significantly to the achievement of the job. The functions should add up to 100%.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

35%

Program Management

Lead and manage the quality program for the physician network, ensuring all relevant data collection, reporting, and compliance are met.

Plans and forms stakeholder workgroups, develops and agrees to scope of work documents, communicates with project participants and stakeholders, develops work plans, tracks actions and decisions, facilitates and attends meetings, facilitates problem resolution, and monitors and report outcomes.

Develops and implements strategies to maximize performance and achieve health system goals.

Analyzes performance data and trends, identifying areas of improvement and developing corrective action plans.

30%

Yes

Quality Improvement Collaboration

• Participates in or leads clinical and technical teams on broad-scope projects using advanced QI models to develop new plans, criteria, and benchmarks
• Researches best practices and develops and implements improvements in the data collection and reporting processes and/or systems
• Serves as a technical leader to provide advice and counsel others on highly-complex QI issues of functionality, efficiency, performance improvement, and program development
• Guide development and collaboration on shared clinical protocols and patient safety & quality activities across UCSF’s Affiliate Network (and alignment on submission strategy across affiliate hospitals and clinics, as needed)
• Develop and guide the implementation of targeted education and training programs for Medical Center Staff and affiliate stakeholders.

25%

Yes

Data Analysis & Reporting

• Analyzes and interprets highly complex data of broad scope, and summarizes statistical findings. Develops and maintains corresponding reports, dashboards, presentations, and action plans. Prepares and delivers executive summaries.
• Coordinate with data teams to ensure accurate and timely aggregation of data reports and dashboards for required stakeholders.
• Generate regular reports for leadership and physicians regarding program status, performance metrics, and opportunities for improvement.
• Identifies trends or cases that require urgent review and collaborates with management as required to develop and implement appropriate responses.

10%

Yes

Compliance Oversight

• Stay current with CMS mandatory health system quality requirements and UCSF executive strategy, ensuring UCSF and network stakeholders remain compliant with organizational and CMS guidelines.
• Conduct periodic audits to ensure accurate submissions and reports.
• Other duties as assigned

100%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

Required qualifications

Five (5) years of related work experience in healthcare quality program management, stakeholder engagement, project leadership, performance improvement, compliance oversight, and implementation of system-wide quality initiatives

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.

Preferred qualifications

Advanced expertise in Epic clinical and administrative workflows

Nursing informatics expertise or competencies in Epic Clarity Data Model, business intelligence tools (tableau), Epic Radar and/or Epic Reporting Workbench.

Lean / Six Sigma

Certified Professionals in Healthcare Quality (CPHQ)

Project Management Professional

Education/Licensure

Master’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and/or experience

Current California RN license or other applicable professional clinical license (e.g., Pharmacy, Physical Therapy, Occupational Therapy).