Manager - Quality Improvement (1.0 FTE, Days)

This job posting is no longer active

Category: Quality
Job Type: Full-Time
Shift: Days
Req: 15629
FTE: 1


1.0 FTE, 8 Hour Day Shift

At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary


This paragraph summarizes the general nature, level and purpose of the job.


The Manager - Quality Improvement contributes to, manages, and executes the development and implementation of a comprehensive program to systematically measure, prioritize, and monitor quality of patient care and promote a culture of safety as well as identify opportunities for improving the quality of patient care at Lucile Packard Children's Hospital Stanford. The Manager has primary oversight of the hospital's quality improvement initiatives and collaborates with others within the organization to improve processes and services that will reduce unintended adverse patient outcomes, improve patient satisfaction, integrate evidence-based practice and coordinate process design/redesign activities.

This position is part of the Quality & Safety leadership team as well as the Quality and Performance Improvement leadership team. The Manager directly manages the quality improvement function, which includes the Quality Improvement Team. Other responsibilities include developing and maintaining strong collaborative relationships with organization-wide divisions and members of the medical staff to ensure open communication and the sharing of information; working with the Director for Quality and Performance Improvement to ensure that the Quality Assurance and Performance Improvement (QAPI) structure within the organization adheres to standards set forth by various accreditation and regulatory agencies (CMS, Title 22, etc.).


 Essential Functions


The essential functions listed are typical examples of work performed by positions in this job classification.  They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities.  Employees may also perform other duties as assigned.


Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.


Must perform all duties and responsibilities in accordance with the hospital’s policies and procedures, including its Service Standards and its Code of Conduct.

  • Develops and manages Quality Assurance structures within LPCHS in conjunction with leadership from Performance Improvement, Medical Staff and Nursing.

  • Strategically assesses the effectiveness of current quality programs in achieving organization objectives. Analyses trending of data related to initiatives, best practices, and benchmarks. Develops recommendations for modifications to align to quality strategy and business goals.

  • Supports the development and integration of new and /or existing quality programs, policies and procedures to ensure that programs support improve efficiency, quality safety, and cost-effectiveness of patient care. Keeps abreast on quality improvement practices. Determines and implements metrics that assess and monitor the effectiveness of ongoing quality programs and new initiatives.

  • Designs, establishes, and maintains an organizational structure and staffing to effectively accomplish the organization's goals and objectives; recruits, employs, trains, supervises, and evaluates quality staff. Develops and promotes quality philosophies, strategies, and policies. Directs and oversees the design and implementation of quality projects, initiatives, and services that are responsive to needs and objectives of the institution.

  • Develops and maintains collaborative and cross-functional relationships with other cpmV departments. Provides leadership and consultation to hospital management on high-impact issues, providing education in the area of quality improvement to departments, providers, and the community and assists in ensuring compliance with regulatory and accrediting organizations. Represents Quality Improvement function and serves as internal consult for relevant organizational committees.

  • Provides leadership and assists with LPCHS strategy and priorities in eliminating Hospital Acquired Conditions by active participation in the HAC Leadership Meeting. Provides guidance regarding quality practices, policy interpretation, problem resolution, and compliance with state and federal regulations and Joint Commission accreditation standards, including the National Patient Safety Goals.

  • Provides forums to address cross-population, department, service quality management and safety issues related to patient care, professional practice, education and research and engages physicians and hospital and clinic staffs in quality and safety improvement activities, encouraging accountability for quality at every level of the organization.

  • Effectively collaborates with external partners, including participation in a national network of quality improvement professionals, sharing best practices, tools and materials while participating in ongoing communication activities and capacity-building peer exchanges.

  • Fosters and maintains collaborative relationships within the hospital and clinics, the School of Medicine, medical and patient care staffs, and with external agencies and stakeholders related to quality and safety initiatives.

  • Participates in the development and implementation of operating budgets and management decision making of overall resource requirements (e.g. people, systems, and equipment). Demonstrates problem solving, leadership, conflict management, and team building skills in order to ensure a productive work environment and achievement of goals.

  • Engages in department level rounding on staff and stakeholders to understand front line quality improvement issues and opportunities for support.

  • Serves as a back-up Survey Operations Center co-leader during all large scale regulatory and accreditation visits.

  • Performs management functions by interviewing and hiring staff members; providing or arranging for training for subordinates; evaluating performance; and recommending or initiating personnel actions such as promotions, transfers, merit salary increases, or disciplinary action in order to ensure adequate and competent staffing as well as initiating or recommending responses to employee grievances.


 Minimum Qualifications


Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.


Education: Master's degree in a work-related discipline/field from an accredited college or university.

Experience: Seven (7) years of progressively responsible and directly related work experience.

License/Certification: None Required.


 Knowledge, Skills, & Abilities


These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.

  • Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation, specifically including ability to apply statistical process control (SPC) and use of software required to generate SPC analysis (e.g., QI Macros)

  • Knowledge of the healthcare delivery system and the broader societal context (e.g., economic, regulatory, legal) in which it operates.

  • Knowledge of improvement science. Ability to practice and to develop as an ability in others.

  • Ability to balance a high level of personal accountability with ability to work in a highly collaborative manner with both operational owners of quality and other support roles.

  • Ability to accomplish work via influence. Requires ability to build understand and trusting relationships via practice of humble inquiry and other related skills. Requires skill in securing stakeholder buy-in both directly and indirectly by working through others.

  • Ability to communicate effectively to facilitate positive working relationships and achieve desired outcomes. Requires excellent interpersonal skills nad large group facilitation skills.

  • Ability to combine a high level of client/customer service with a mission-driven approach to work that is grounded in improvement science methods

  • Mission-driven, client/customer-service orientation

  • Ability to collaborate with partners with a high degree of specialization in a wide variety of disciplines (e.g., medicine, nursing, infection control, data science, clinical informatics)

  • Ability to adapt to the changing needs of the organization and assigned areas.

  • Ability to provide leadership and influence others

  • Ability to supervise, coach, mentor, train, and evaluate work results


Physical Requirements and Working Conditions

The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.

Equal Opportunity Employer

Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.