Providence St. Joseph Health

Job Information

St. Joseph Health / Covenant Health Senior Manager Quality Improvement - Clinical Excellence in Fullerton, California

We are looking for a Senior Manager Quality Improvement for the Clinical Excellence Department at St. Jude Medical Center.

Location: Fullerton, CA

Work Schedule: Full Time - 80 Biwekly Hours

Shift: 8-hour, Days

Job Summary:

Under the direction of the service area executive director quality the senior manager quality improvement and data analytics, this position will be responsible for planning, designing and directing performance improvement work in alignment with the Value Triple Aim (Quality, Service and Cost Excellence). The Senior manager will coordinate and develop the infrastructure and strategies to facilitate the implementation of Performance Improvement and achievement of PSJH goals, including integration of system-wide and ministry strategic initiatives, and performance improvement strategies, projects, and activities with system, region, and local ministry priorities in coordination with quality and performance improvement leaders. They ensure the proper preparation and coordination efforts to achieve regulatory compliance with The Joint Commission and other regulatory agencies for Quality Indicators.

The senior manager quality improvement and data analytics develops, monitors and effectively regulates departmental budgets. Serves as a catalyst and mentor for motivating productivity, innovation, high employee morale and commitment to the organization.

Essential Functions:

  • Oversight of Analysis and Tracking:

  • Performs data analysis and develops/drives and executes innovative strategies to achieve Quality, Service, and Strategic goals. Monitors and reports ministry progress to executive leadership in PI and Strategic Implementation. Develops, coordinates and implements sustainability progress on improvement activities in collaboration with improving performance leaders at the system, regional and local ministry level.

  • Act as primary resource to Service Line leaders to provide data for decision making including VOA cost data, clinical outcomes, LOS, payment data from payors, physician outcomes.

  • Provide outcomes for different payor designations, i.e., Blue Distinction, Anthem Create monthly quality report for presentation by Executive Lead by pulling most current data and working with leaders for their input.

  • Develop trend charts puling most appropriate data for all Magnet outcomes related to clinical stories.

  • In collaboration with care experience leader, Provide Patient Experience outcomes from Press Ganey related to overall outcomes for hospital, units/departments, physicians.

  • Support Stroke service line support for Comprehensive Stroke certification with support of RedCap tool for all Code Stroke data and data flow into Quintiles and Joint Commission.

  • Responsible for external data reporting: Clean all errors in data transmission file prior to upload to Premier. Enter Hip & Knee abstractions and CSTK Stroke abstractions in Joint Commission website.

  • Review all CMS and JC data abstractions with Q Centrix team, including stroke, hip and knee, and all other required quality metrics. Review for fallouts and for accuracy.

  • Review all CMS readmissions with service line leads and coordinate action plans with regional service area executive director of quality.

  • Review mortalities >3 ROM score coordinate action plans with regional service area executive director of quality.

  • Build monthly and ad hoc reports in WEBI and AMALGA to review trends for exec team and unit leaders.

  • Act as hospital’s QNET administrator – upload required outcomes, i.e., CDAC validation outcomes. Download measure outcomes, PEPPER reports, etc.

  • Maintains confidentiality of all information related to patients, medical staff, employees, and as appropriate, other information.

  • Demonstrates service excellence and positive interpersonal relations in dealing with others.

  • Facilitates the PI process throughout the organization acting as a facilitator and mentor for department improvement teams.

  • Assures the standardization and consistency of quality performance improvement activities throughout the organization.

  • Works collaboratively with regional service area Executive Director Quality PI/Patient Safety/Accreditation leaders to develop standardized processes and share “learnings” throughout the community, region, and Providence Health and Services System.

  • Facilitates the establishment of organization monitoring and evaluation of PI/patient safety activities using identified quality indicators.

  • Assists in the orientation and ongoing education of employees in the quality performance improvement process in collaboration with regional PI team.

  • Provides staff support for identified organization quality committees/councils and service lines.

  • Interprets raw data and performs and/or facilitates comparative analysis of clinical data.

  • Assists in the development, revision and evaluation of quality improvement plans. Actively works with physician leadership, directors and managers in the development and implementation of quality performance improvement plans.

  • Keeps regional executive director quality , physicians and management apprised of issues requiring actions and communicates regularly about progress/trends toward key quality indicators.

  • Supervises the collection, assessment and presentation of information to facilitate the ongoing measurement of processes and outcomes.

  • Assists, as necessary, in the collection of data for the defined indicators.

  • Develops systems and processes to assure the reliability, accuracy and confidentiality of information used in the department functions.

  • Works collaboratively with Risk Management, Patient Safety, and Regulatory on the integration of risk, patient safety, quality improvement and regulatory compliance.

  • Collaborates with regional executive director of quality to support Medical Staff leadership in the development and implementation of systems and processes to identify practice variations and opportunities for improvements in patient care processes and/or outcomes for the organization.

  • Collaborates with regional executive director of quality and the use of regional PI staff’s use of the performance improvement methodology to provide PI support to the organization.

  • Works collaboratively with the Accreditation and Licensure area on ongoing survey readiness.

  • Provides comprehensive reports of quality performance improvement activities to the PI teams and Medical Staff, Medical Executive Committee, and the Medical Affairs Committee.

  • Serves as a coach and mentor to direct reports.

  • Maintains professional growth and development through participation in seminars, educational programs, workshops, and professional affiliations.

  • Participates in medical staff, service line , organization meetings as required.


  • Demonstrate a working knowledge of national healthcare trends in quality improvement and management.

  • Working knowledge of The Joint Commission standards and/or regulatory agency requirements regarding PI/Quality.

  • Work efficiently and effectively in a matrix structured environment.

  • Understand the needs and preferences of customers served.

  • Strong presentation and interpersonal skills that display a presence of leadership in a wide range of settings.

  • Skills:

  • Quality and Safety.

  • Driving improvement.

  • Risk Assessment.

  • Conflict Resolution.

  • Staff Development.

  • Interpersonal Communication.

  • Organized, detail oriented and like to work with statistics and evaluation of methodologies.

  • Efficiently problem solve, while dealing with a diverse set of systems and individuals.

  • Developing and motivating staff to their highest potential, using strong leadership skills and interpersonal communication skills.

  • Significant discretion and knowledge of department to prioritize work load.

  • Respond to multiple duties simultaneously.

  • Demonstrates expertise in healthcare data analytics with the ability to take complex data sets, effectively data mine, and through analysis identify pertinent insights an interpretation providing actionable insights to drive quality improvement activities.

Minimum Position Requirements:

Education: Bachelor's Degree in Health-related field.

Experience: Two (2) years Acute care setting practicing within specified licensure.

Preferred Position Qualifications:

Education: Master's Degree

Experience: Three (3) years Progressive hospital leadership positions.


  • Current California Registered Nurse License, or equivalent or higher level licensure or equivalent experience and expertise in quality data analytics.

  • Certified Professional in Healthcare Quality CPHQ.

St. Jude Medical Center is a faith-based, non-profit, 384-bed, tertiary care facility, and is one of Southern California's most-respected and technologically-advanced hospitals. With nearly 700 of the area's finest physicians on staff, St. Jude offers nearly every medical specialty and sub-specialty. Whether for the birth of a baby, life-saving surgery or a routine mammogram, St. Jude continues to set the standard for medical care and offers the community the most comprehensive array of services and programs.

St. Jude Medical Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, St. Jude Medical Center complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Positions specified as “on call/per diem” refers to employment consisting of shifts scheduled on as “as needed basis” to fill in for staff vacancies.

Company: St. Jude Medical Center

Category: Clinical Lead Supervisor/ Manager

Req ID: R328418