Job Summary: Responsible for planning and implementing the performance improvement program to meet the
needs of the clinic. Provides education to medical staff, clinic staff and Governing Body. Facilitates performance
improvement activities and CQI activities throughout the clinic. Acts as resource person to administrative team,
department managers and medical staff. Performs clinical risk management functions. Assists department managers
with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, i.e., the Joint
Commission, State Licensing Review, CMS Validation surveys. Maintains oversight responsibility for all performance
improvement activities conducted throughout the institution.

Demonstrates Competency in the Following Areas:

Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the clinic.

Ability to facilitate performance improvement and CQI activities throughout the clinic.

Demonstrates effective organizational skills through ongoing interaction with clinical
chairpersons, nurse managers, ancillary department managers, administrative team and
Governing Body to facilitate the clinicwide PI program.

Demonstrates knowledge of current methodology and practices. Maintains awareness of
changes in the regulations and requirements by accrediting bodies.

Practices good guest relations with patients, visitors, physicians and staff, assists as
needed.

Manages and operates equipment safely and correctly.

Demonstrates awareness of the responsibilities of the position and how it interfaces with
the rest of the healthcare team. Works closely with all department members as required,
is flexible to meet the needs of the department and changes in the workload.

Communicates appropriately and clearly to physicians, staff, Nurse Executive and
administrative team.

Accurately demonstrates use of database systems to document occurrences, medical
staff review functions, committee review and actions. Compiles reports for committees.
and administrative team.

Oversees preparation for review by regulatory agencies, educates and assists department
managers to maintain appropriate policies and procedures to fulfill requirements and
regulations.

Demonstrates an ability to be flexible, organized and function under stressful situations.

Maintains a good working relationship both within the department and with other
departments.

Consults with other departments as appropriate to collaborate in patient care and
performance improvement activities.

Participates in risk management and safety activities.

Documentation meets current standards and policies.

Provides support and assistance to medical staff officers, committee chairpersons and
Governing Body, as required.

Utilizes information obtained via performance improvement activities to seek and act on
opportunities to improve patient care processes.

Consistently demonstrates a professional, self directed, mature, disciplined and tactful
approach to department responsibilities.

Supports and maintains a culture of safety and quality.

Professional Requirements:
Adheres to dress code, appearance is neat and clean.

Completes annual education requirements.

Maintains regulatory requirements, including all federal, state, local regulations and
accrediting organization standards.

Maintains and ensures patient confidentiality at all times.

Reports to work on time and as scheduled.

Wears identification while on duty.

Attends annual review and performs departmental in-services.

Works at maintaining a good rapport and a cooperative working relationship with
physicians, departments and staff.

Represents the organization in a positive and professional manner.

Attends committee and management meetings, as appropriate.

Resolves staff concerns at the departmental level, utilizing the grievance process as
required.

Ensures compliance with policies and procedures regarding department operations,
firesafety, emergency management and infection prevention and control.

Effectively and consistently communicates administrative directive to staff and encourages
interactive departmental meetings and discussions.

Complies with all organizational policies regarding ethical business practices.

Communicates the mission, ethics and goals of the facility, as well as the focus statement.
of the department.

Regulatory Requirements:
Current RN licensure in State of California.
CPHQ certification preferred.
Additional course work in performance improvement and CQI.
Three (3) or more years of previous experience in acute care nursing.
Previous experience in performance improvement activities preferred.
Language Skills:
Able to communicate effectively in English, both verbally and in writing.
Additional languages preferred.
Strong written and verbal skills.
Skills:
Basic computer knowledge.
Word processing and database management preferred.
Physical Demands:
For physical demands of position, including vision, hearing, repetitive motion and environment, see following
description.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential
functions of the position without compromising patient care.

Requirements

1. Resume (if available).
2. Application/Candidate Profile.
3. Immunization record (showing completion of MMR, HEP B, Flu, Covid-19 Dose (Comirnaty or Spike)
4. PPD documentation within 1 year. (Individuals with a history of a positive PPD must provide a note for their provider indicating they are free of active disease, a blood test or chest x-ray with the last year.)

Please note that this job description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.