Jan 10, 2022

Quality Improvement RN Specialist - Performance Improvement *$20,000 Sign-On-Bonus*

  • Providence
  • Santa Rosa, CA, USA
General Nursing

Job Description

We are looking for a Quality Improvement RN Specialist for the Performance Improvement - Area Department at Santa Rosa Memorial Hospital. Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.

Sign-on Bonus for eligible external candidates who meet all conditions for payment - this is in addition to the fantastic benefits and compensation package offered by Providence that begin on your first day of employment.

Location: Santa Rosa, CA

Work Schedule: Full Time - 80 Biweekly Hours

Shift: 8-hour, Days

Job Summary:

The Quality RN Specialist supports the Performance Improvement Department's management team in the planning and implementation of a systemic program for clinical quality and outcomes improvement efforts. The position serves as primary support to population focus Medical Staff Quality Committees (e.g., Medicine, Surgery, Neurology, Emergency Medicine, etc.) in the monitoring and evaluation of processes for clinical performance improvement and peer review. The Coordinator supports concurrent oversight and review of clinical quality measures and evidence-based standards of care for high risk, high volume populations (e.g., Stroke, diabetes, heart disease, etc.).

Essential Functions:

  • Leads and/or facilitates clinical performance improvement teams/taskforce as indicated.
  • Serves as a team facilitator and consultative resource for clinical and departmental leadership and staff responsible for quality and performance improvement activities.
  • Promotes quality culture to population based multidisciplinary quality/performance improvement teams.
  • Supports and assists Quality Department management team in the implementation and monitoring of the Hospitals’ clinical quality improvement efforts. This may include concurrent oversight of Core Measure compliance.
  • Supports and maintains records, minutes, and data from population based quality committees, ad hoc PI teams, and other strategic quality initiatives in accordance with SJH confidentiality, and Federal and State regulatory guidelines.
  • Participates in regulatory activities and surveys, using working knowledge of CMS/Joint Commission, and Title 22 standards.
  • Attends medical staff committee meetings with punctuality (meetings may occur at varying frequency throughout the day, including early morning and late evening).
  • Collaborates with Committee Chairs in developing meeting agendas and setting priorities and in leading improvement efforts related to Quality/Peer Review.
  • Risk Management:
  • Under the supervision of the Area Risk Director, supports the Performance Improvement Program including the relevant duties associated with Medical Staff and all Ancillary services risk management needs and services.
  • Investigates reported occurrences utilizing the approved SJHS RCA investigation tool kit and develops strategies for management of serious adverse events.
  • Interviews health care providers, patients and family members involved in occurrences within 24 hours of knowledge of event.
  • Researches medical records, policies and procedures to gather information required for further analysis. Able to navigate multiple information systems as part of standard investigations and documents timely.
  • Sequesters and maintains custody of all evidence collected in an investigation.
  • Seeks outside expertise from agencies like the FDA, ISMP, and CDC etc. when investigations demand expertise beyond the capacity of the ministry.
  • Serves as facilitator for root cause analysis meetings conducted in response to serious safety events.
  • Analyzes individual occurrence reports in RL solutions and trends to identify opportunities to improve the delivery of safe patient care. Recommends changes in policies, practice and procedures to prevent patient injury.
  • Submits SJHS required tracking data that includes open RLs, open RCAs, complaints and grievances and other metrics as requested.
  • Monitors compliance with loss prevention activities.
  • Prepares and maintains summaries of investigations, recommendations and corrective action plans in RL System database.
  • Collects, evaluates, analyzes, and displays statistical data to identify trends or opportunities for improvement utilizing CQI statistical techniques.
  • Assists the Quality Managers in investigating, evaluating, and recommending problem-solving methodologies where outcomes would necessitate corrective actions.
  • Utilizes other PI tools like FMEA, SWOT, and Simulation as required.
  • Collaborates with Medical Staff and hospital departments to formulate corrective plans for identified opportunities for improvement.
  • Facilitates progress with multidisciplinary performance improvement projects.
  • Facilitates appropriate groups to develop recommendations for quality improvement.
  • Facilitates development of departmental quality review processes.


  • Demonstrates a thorough working knowledge and competency in using the following systems: MEDITECH; Microsoft Office application including but not limited to Word, Excel, PowerPoint; Visio; and creates reports for presentation to medical staff committees.
  • Knowledge of CMS Core Measure guidelines.
  • Demonstrates a thorough working knowledge and competency in the utilization of PI framework and tools such as rapid cycle improvement, PDCA, Lean, Root Cause Analysis (RCA) and Failure Mode Effects Analysis (FMEA).
  • Demonstrates knowledge of basic workflow in a clinical setting. Has an in depth understanding of population-based care and evidence-based practice standards

Minimum Position Requirements:


  • Coursework/Training - Graduate of accredited School of Nursing.
  • Risk Management: Bachelor's Degree in Nursing or Healthcare related field.


  • Risk Management:
  • 4 years in working in healthcare environment.
  • Preferred: 2 years working in healthcare quality management.

Licenses/Certifications: Current California RN Licensure.

Preferred Position Qualifications:

Experience: 3 years experience in Quality Improvement.

Providence St. Joseph Health (Providence) has worked for decades to improve health and quality of life in California's North Bay region, starting in Sonoma County, where the Sisters of St. Joseph of Orange opened the doors of Santa Rosa Memorial Hospital in 1950. Today, we continue the mission begun by the Sisters to those we serve through an integrated spectrum of primary, urgent, acute, outpatient, palliative care and regional referral services. Sonoma County facilities aligned with Providence include the 278-bed Santa Rosa Memorial Hospital, the region's only Level II trauma center. In addition, the 80-bed Petaluma Valley Hospital and 43-bed Healdsburg Hospital are secular (non-religious) affiliates of Providence. Our services also encompass three Urgent Care centers, Hospice of Petaluma, Memorial Hospice and North County Hospice, the Annadel Medical Group doing business as St. Joseph Health Medical Group, as well as the St. Joseph Home Care Network (post-acute care services). We act as a regional referral hub for outlying hospitals, while also providing outpatient behavioral health care, education to promote health and prevent chronic disease, rehabilitation, oral health care, community benefit programs, and more, all fostering health and quality of life throughout the area.

Providence 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, Providence 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: Sonoma County Entities

Category: Quality Nursing

Req ID: R334349