Coordinate day to day obligations required of assigned programs including oversight of multidisciplinary teams involved with implementation of regulatory requirements/accreditation standards, risk reduction, service enhancement, performance improvement initiatives, and best practice strategies.
This position requires the full understanding and active participation in fulfilling the mission of Saddleback Medical Center. It is expected that the employee demonstrate behavior consistent with our core values: Integrity, Accountability, Best Practices, Compassion and Synergy. The employee shall support Saddleback Medical Center’s strategic plan and participate in and advocate performance improvement/patient safety activities.
Coordinates chart review and accurately performs chart abstraction for data registries and public reporting measures. Ensures accurate data collection, analysis, and timely submission to all outside data registries, regulators, and payors; including, but not limited to Core Measurements, CalNoc, STS, etc.
Prepares data for internal and external reporting. Coordinates and ensures the integrity/validity of electronic databases. Facilitates organizational understanding of reported data through presentation of data analysis, and interpretation of specifications and fallouts.
Identifying, communicating, and facilitating PI efforts (clinical, service, safety, Lean) and supporting the organization in striving to meet Bold Goals as well as on-going compliance with all regulatory/accreditation standards.
Incorporates Lean strategies and is an active participant with inter/intradepartmental Lean Activities including Daily Management System (DMS) and Lean Management System (LMS)
Coordinates collection of post-survey (CMS, CDPH, TJC, etc.) results, including audits.
Communicates improvement opportunities and successes to the organization.
Facilitates strategic quality, safety and improvement initiatives.
Ensure policies meet regulatory guidelines.
Minimum of two (2) years’ experience in a clinical healthcare setting, required
Three (3) years acute care experience in specialty specific and/or population specific, preferred
Six Sigma, Lean/Toyota Way, or other improvement model certification, preferred
Certified Professional in Healthcare Quality (CPHQ) or other Quality/Safety certification, preferred
Knowledge/experience with Microsoft Office products and/or database management
Excellent oral and written communication skills as well as presentation skills
Excellent interpersonal and organization development (i.e., teambuilding) skills
Proficient with electronic organizational and data management skills, including word processing, spreadsheets, data entry into data base systems and data analysis skills
Expertise in quality, safety, and regulatory standards supported/required by external agencies including, but not limited to, The Joint Commission, Centers for Medicare and Medicaid Services (CMS), California Department of Public Health and the Institute for Medical Quality.
Graduate of an accredited RN School of Nursing, required
Under graduate degree or in progress near completion, required. Masters preferred.
Current CA RN license, required
Other current certification or licensure, as applicable
Current certification of advanced, specialized study (such as CPHQ, CIC, HACP, etc.), preferred
Internal Number: SAD002626
About MemorialCare Saddleback Medical Center
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.