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Director - Adult Quality Improvement (QUALITY IMPROVEMENT HC MGR 2)

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POST DATE 9/2/2016
END DATE 1/8/2017

University of California - San Francisco Medical Centers San Francisco, CA

San Francisco, CA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Job Title

Director - Adult Quality Improvement (QUALITY IMPROVEMENT HC MGR 2)

Job ID


Job Code


Job Family



Geary Blvd

Weekly Hours

40 ; 100%

Appointment Type



Qlty Improvement


8-hour Days

Full/Part Time


Union Information

This classification is not represented by a union

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Our legacy of unsurpassed patient care and unceasing mission to integrate high-tech medical research with clinical operations has led to our prestigious standing as one of the top 10 hospitals in the nation according to U.S. News & World Report. As a premier health care institution dedicated to advancing health worldwide, UCSF Medical Center can also be the best place to advance and shape your career.

The medical center's employees are one of the most important reasons why we are recognized as one of the nation's best hospitals. To work at UCSF Medical Center is to be part of an institution that provides the highest caliber of care to patients; a nurturing, dynamic and team-oriented atmosphere in which to best use your skills and talents.

Job Summary

Adult Quality Improvement is a unit of the Department of Quality that provides clinical quality improvement program support to adult medical and surgical departments. Adult QI manages CMS and Joint Commission quality reporting programs, supports several clinical outcomes registries, coordinates hospital wide and multi-hospital quality initiatives and collaboratives.

Under the general direction of the Executive Director for Quality, the Director of Adult Quality Improvement provides strategic director level leadership, planning, organization and management for all aspects of Adult Quality Improvement.

Designs and manages the implementation of quality programs and initiatives as outlined by the Department of Quality and UCSF Health s organizational quality goals and priorities. Establishes and maintains systems and standards for all quality reporting, maximizing integration with current systems and providing vision for the future. Develops and maintains a coordinated approach to quality programs in collaboration with other UCSF quality partners (e.g., Lean, CPI Hub, Nursing PI, Health Experience). Leads and directs staff to provide expert support for quality and safety committees and clinical departments within UCSF Health. Assures accuracy and timeliness of reporting of publicly reported quality measures and adherence to quality regulatory requirements. Contributes to strategic plans and policies that have impact throughout the medical center.

The flexibility to orient and work at all UCSF Medical Center locations is required.

Required Qualifications

* Bachelor s degree in nursing or related health care field, or equivalent combination of education and experience (8+ years experience)

* Strong hospital management experience, with progressive and in-depth expertise in quality and process improvement methodologies, statistical analysis, and data base management

* Excellent skills in developing strategic plans, creating benchmarks, integrating programs, building staff competencies, organizing operations, and fiscal management

* Excellent leadership and fiscal management skills, with the ability to create a goal-oriented climate of teamwork, collaboration and consistent achievement of objectives

* Advanced analytical, organizational, and problem-solving skills, with in-depth ability to develop and pursue goals, synthesize data to identify system vulnerabilities and develop and apply innovative solutions

* Strong knowledge of relevant healthcare information technology, including QI workflows and processes, relevant systems and data management techniques and methodologies

* Strong knowledge of relevant QI regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments

* The flexibility to orient and work at all UCSF Medical Center locations is required

Preferred Qualifications


* LEAN training or certification

* Advanced degree in nursing or related health care field (e.g., MPH, MBA, etc,) or equivalent combination of education and experience


* N/A

Living Pride Standards

Service Excellence

* Demonstrates service excellence by following the Everyday PRIDE Guide with the UCSF Medical Center standards and expectations for communication and behavior. These standards and expectations convey specific behavior associated with the Medical Center s values: Professionalism, Respect, Integrity, Diversity and Excellence, and provide guidance on how we communicate with patients, visitors, faculty, staff, and students, virtually everyone, every day and with every encounter. These standards include, but are not limited to: personal appearance, acknowledging and greeting all patients and families, introductions using AIDET, managing up, service recovery, managing delays and expectations, phone standards, electronic communication, team work, cultural sensitivity and competency.

* Uses effective communication skills with patients and staff; demonstrates proper telephone techniques and etiquette; acts as an escort to any patient or family member needing directions; shows sensitivity to differences of culture; demonstrates a positive and supportive manner in which patients / families/ colleagues perceive interactions as positive and supportive. Exhibits team work skills to positively acknowledge and recognize other colleagues, and uses personal experiences to model and teach Living PRIDE standards.

* Exhibits tact and professionalism in difficult situations according to PRIDE Values and Practices

* Demonstrates an understanding of and adheres to privacy, confidentiality, and security policies and procedures related to Protected Health Information (PHI) or other sensitive and personal information.

* Demonstrates an understanding of and adheres to safety and infection control policies and procedures.

* Assumes accountability for improving quality metrics associated with department/unit and meeting organizational/departmental targets.

Work Environment

* Keeps working areas neat, orderly and clutter-free, including the hallways. Adheres to cleaning processes and puts things back where they belong. Removes and reports broken equipment and furniture.

* Picks up and disposes of any litter found throughout entire facility.

* Posts flyers and posters in designated areas only; does not post on walls, doors or windows.

* Knows where the Environment of Care Manual is kept in department; corrects or reports unsafe conditions to the appropriate departments.

* Protects the physical environment and equipment from damage and theft.

Equal Employment Opportunity

The University of California San Francisco is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Further information about the University of California, San Francisco, is available at UCSF seeks candidates whose skills, and personal and professional experience, have prepared them to contribute to our commitment to diversity and excellence, and the communities we serve.


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