Quality Improvement HC Specialist 1-5

Job Summary

Involves the establishment and supervision of processes (e.g., performance improvement, clinical documentation, etc.) to achieve the optimal degree of excellence in the services rendered to every patient. Evaluation of practice operates within the parameters of patient outcome, cost-benefit in care provision, and patient access to the health care delivery system. Provides for internal strategic planning efforts and implementing continuous quality improvement programs.

Job Title	Quality Improvement HC Specialist 1 HX	Quality Improvement HC Specialist 2 HX	Quality Improvement HC Specialist 3 HX	Quality Improvement HC Specialist 4 HX	Quality Improvement HC Specialist 5 HX
Job Code	5180	5181	5182	4916	4917
Bargaining Unit	HX	HX	HX	HX	HX
FLSA	Non-Exempt	Non-Exempt	Exempt	Exempt	Exempt
Generic Scope	Entry-level professional with limited prior experience; learns to use professional concepts to resolve problems of limited scope and complexity; works on assignments that are initially routine in nature, requiring limited judgment and decision making. Employees at this level are expected to acquire the skills and knowledge to perform more advanced work following an agreed upon time in position, through defined training and development planning.	Professional who applies acquired job skills, policies, and procedures to complete substantive assignments / projects / tasks of moderate scope and complexity; exercises judgment within defined guidelines and practices to determine appropriate action.	Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field. Independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.	Technical leader with a high degree of knowledge in the overall field and recognized expertise in specific areas; problem-solving frequently requires analysis of unique issues / problems without precedent and / or structure. May manage programs that include formulating strategies and administering policies, processes, and resources; functions with a high degree of autonomy.	Recognized organization-wide expert. Has significant impact and influence on organizational policy and program development. Regularly leads projects of critical importance to the organization; these projects carry substantial consequences of success or failure. Directs programs with organization-wide impact (or may have impact beyond the University) that include formulating strategies and administering policies, processes, and resources. Significant barriers to entry exist at this level.
Custom Scope	Under direct supervision, acquires skills and knowledge of professional concepts in quality analysis and / or improvement (QI) to assist on small projects or segments of projects. This title is bargaining unit only. There should never be an uncovered position.	Applies acquired skills and professional concepts to quality data analysis and / or improvement (QI) projects of small to medium size and intermediate scope and complexity. This title is bargaining unit only. There should never be an uncovered position.	Applies skills and experience as a seasoned quality data and / or improvement (QI) specialist to projects of medium size at all levels of complexity, or to portions of large projects. Typically, the bargaining unit job code should be used for work covered by this title. However, if the position is not covered by the Higher Education Employer-Employee Relations Act (HEERA) due to one of the following reasons—(1) Confidential status, where duties normally require access to confidential information that significantly influences the development of management’s bargaining or grievance positions; (2) employed outside of California at a location with 100 or fewer employees; or (3) Supervisory status, where duties include supervising employees as a regular part of the job—then the position should be listed under the generic title without the “HX” ending.	Applies extensive knowledge of quality data analysis and / or improvement (QI) concepts, methodologies, and data collection and abstraction techniques to substantial projects of large scope and high degrees of complexity. Typically, the bargaining unit job code should be used for work covered by this title. However, if the position is not covered by the Higher Education Employer-Employee Relations Act (HEERA) due to one of the following reasons—(1) Confidential status, where duties normally require access to confidential information that significantly influences the development of management’s bargaining or grievance positions; (2) employed outside of California at a location with 100 or fewer employees; or (3) Supervisory status, where duties include supervising employees as a regular part of the job—then the position should be listed under the generic title without the “HX” ending.	As a recognized quality data analysis and / or improvement (QI) expert, applies comprehensive knowledge of professional concepts and industry practices to lead the most complex projects of large size and scope that have critical impact throughout the medical center and / or organization. Typically, the bargaining unit job code should be used for work covered by this title. However, if the position is not covered by the Higher Education Employer-Employee Relations Act (HEERA) due to one of the following reasons—(1) Confidential status, where duties normally require access to confidential information that significantly influences the development of management’s bargaining or grievance positions; (2) employed outside of California at a location with 100 or fewer employees; or (3) Supervisory status, where duties include supervising employees as a regular part of the job then the position should be listed under the generic title without the “HX” ending.
Key Resp 01	Acquires skills and knowledge in utilizing internal and external sources to collect, verify, and abstract data related to quality of patient care.	Utilizes internal and external sources to collect, verify, and abstract moderately complex data related to quality of patient care. Assists with the development of appropriate data reporting structures to support quality reviews for new initiatives.	Supports designated clinical areas on data management including establishing systems to acquire data. Develops appropriate data reporting structures to support quality reviews for new initiatives.	Supports clinical areas on data management activities and projects with significant clinical complexity and organizational scope. Develops relevant department and service quality indicators, structures and measures.	Defines the process components and methodologies of the quality improvement program for the medical center or system. Establishes clinical monitors and outcome measures as determined by regulatory agencies or internal departments.
Key Resp 02	Under direct supervision, analyzes and interprets data of limited scope and summarizes statistical findings. Develops corresponding dashboards, presentations, and basic reports or portions of larger reports. Assists with developing action plans.	Analyzes and interprets data of moderate complexity and summarizes statistical findings. Develops corresponding reports, dashboards, and presentations. Assists with developing action plans.	Analyzes and interprets data at most levels of complexity and summarizes statistical findings. Develops corresponding reports, dashboards, presentations, and action plans. Participates in development of executive summaries.	Analyzes and interprets highly complex data of broad scope, and summarizes statistical findings. Develops corresponding reports, dashboards, presentations, and action plans. Prepares and delivers executive summaries.	Develops annual plans and proposals to outline the overall quality improvement program structure and design for the medical center or system; includes the goals and objectives and specific projects / action plans.
Key Resp 03	Under direct supervision, acquires skills to identify statistical trends and problems in patient care and services. Participates on small projects or portions of larger projects and learns to contribute to investigations and the development and monitoring of corrective actions.	Applies acquired skills and experience to identify statistical trends and issues in patient care and services. Contributes to moderately-complex projects in assigned clinical areas to assist with investigation of problems, and the development and monitoring of corrective actions.	Identifies statistical trends, and potential issues in patient care and services. Works collaboratively on highly complex projects in assigned clinical departments to develop corrective plans, and monitor their effectiveness.	Identifies statistical trends, problems, and potential issues in patient care and services. Participates in or leads project teams in clinical departments to investigate, develop and implement corrective plans, and monitor their effectiveness.	Determines benchmarks for institutional clinical monitors in conjunction with physicians and leadership. Compares performance against benchmarks; provides proposals and plans to senior leaders to improve quality in patient care.
Key Resp 04	Learns to follow incident-reporting procedures and to conduct case reviews in basic cases of limited scope and complexity. Acquires skills to review cases involving mortalities, sentinel events, readmissions, and to identify cases requiring immediate attention.	Works on incident reports and QI reviews of moderately-complex cases as assigned, including mortalities, sentinel events, and readmissions. Flags cases that may require immediate review and response and develops or participates in development of appropriate actions.	Within assigned clinical departments, prepares incident reports and conducts QI reviews of complex mortality cases, sentinel events, readmissions, and other cases flagged by screening criteria. Identifies cases that require urgent review and provides follow up.	Prepares incident reports and conducts QI reviews of highly-complex mortality cases, sentinel events, readmissions, and other cases flagged by screening criteria. Identifies cases that require urgent reviews and collaborates with management as required to develop and implement appropriate responses.	Conducts QI reviews in the most complex cases involving mortality, sentinel events, readmissions, and other high-level occurrences, including fast-track cases requiring immediate review and response. Follows through to ensure that findings from significant case reviews are incorporated into the QI plans of the appropriate clinical departments.
Key Resp 05	Under direct supervision, assists in preparing reports of patient care and safety data to appropriate internal departments and outside agencies.	Assists in preparing reports of patient care and safety data to appropriate internal departments and outside agencies.	Performs timely and accurate reporting of quality data to appropriate internal departments and outside agencies.	Oversees or performs timely and accurate submission of clinical care quality and patient safety data to appropriate internal departments and outside agencies.	Monitors and ensures timely and accurate submission of clinical care quality and patient safety data to appropriate internal departments and outside agencies.
Key Resp 06	Acquires collaborative skills to work on teams, using basic QI models and techniques to improve clinical care and patient safety, and to learn to identify opportunities for continued quality improvement.	Works with clinical and technical staff on projects of limited scope, applying moderately complex QI models and techniques to improve clinical care and patient safety. Identifies opportunities for continued quality improvement.	Collaborates with clinical and technical project teams to apply complex QI models and techniques to improve clinical care and patient safety; develops plans to improve quality of patient care.	Participates in or leads clinical and technical teams on broad-scope projects using advanced QI models to develop new plans, criteria, and benchmarks.	Initiates or leads clinical and technical teams on comprehensive, systemwide projects, using advanced QI models to develop and implement new methodologies, structures, plans, and criteria. Builds alliances with clinician and physician leaders in developing service quality programs and systems to monitor key performance indicators.
Key Resp 07	Under direct supervision, coordinates the management of data and documents between Quality and other departments. Identifies and recommends changes to streamline the data collection processes.	Under general supervision, coordinates the management of data and documents between Quality and other departments. Assists in researching best practices and in developing proposals for improvements in the data collection processes.	Researches best practices and develops proposals for improvements in the data collection and reporting processes and / or systems.	Researches best practices and develops and implements improvements in the data collection and reporting processes and / or systems.	Develops best practice proposals for new data collection methods and / or data systems for reporting.
Key Resp 08			Provides advice and recommendations on complex clinical QI issues of functionality, efficiency, and program development.	Serves as a technical leader to provide advice and counsel others on highly-complex QI issues of functionality, efficiency, performance improvement, and program development.	Serves as an expert resource on QI within the organization. Provides advice and counsel on optimal strategies and policies for performance improvement and program development in all clinical QI functions.
Education	Bachelor’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience.	Bachelor’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience.	Bachelor’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience.	Bachelor’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience.	Bachelor’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience.
Special Condition	Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.	Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.	Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.	Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.	Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.
KSA 01	Basic knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.	Working knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.	Thorough knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.	In-depth knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.	Expert knowledge of the methods, concepts, systems, and operational issues in clinical QI.
KSA 02	Basic knowledge of QI models, tools, and techniques, including collection, aggregation, abstraction, analysis, and reporting of data.	Working knowledge of QI models, tools, and techniques, including collection, aggregation, abstraction, analysis, and reporting of data.	Thorough knowledge of QI models, measurement tools, and techniques, including collection, aggregation, abstraction, validation, analysis, and reporting of data.	In-depth knowledge of QI models, tools, and techniques, including collection, abstraction, validation, analysis, reporting of data, and use of performance and benchmark indicators.	Expert knowledge of QI models, tools, and techniques, including collection, abstraction, validation, analysis, reporting of data, and the development and application of performance and benchmark indicators.
KSA 03	Detail oriented, with basic organizational skills and the ability to manage time efficiently.	Detail oriented, with demonstrated organizational skills and the ability to complete projects and tasks on a timely basis.	Detail oriented, with proven ability to effectively manage time, see projects through to completion, organize competing priorities, and effectively address complex, urgent issues as they arise.	Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see projects through from inception to completion on schedule.	Highly developed skills and expertise in project management, with demonstrated ability to initiate projects and lead teams, prioritize tasks, and direct projects successfully from inception to completion on task and on schedule.
KSA 04	Acquiring problem solving skills to assess problems quickly and propose options for effective and timely resolution.	Demonstrated problem solving skills to assess problems quickly and develop multiple options for effective and timely resolution.	Strong critical thinking and problem solving skills to manage multiple levels of information and responsibilities, to quickly assess complex problems, and to develop and implement timely and effective solutions.	Advanced critical thinking and problem solving skills to manage multiple levels of highly-complex information and responsibilities, to quickly assess problems, and to develop and implement timely and effective solutions.	Expert ability to use highly-developed critical thinking and problem-solving skills to manage multiple levels of information and responsibilities, and to quickly diagnose and resolve extremely complex issues, and to develop and implement timely and effective solutions.
KSA 05	Basic interpersonal skills for collaborating effectively with clinical and technical staff.	Demonstrated interpersonal skills for collaborating effectively with a range of clinical and technical staff and representatives of external regulatory agencies.	Strong interpersonal skills for collaborating effectively with a broad range of clinical and technical staff and representatives of external regulatory agencies and for mentoring lower-level QI staff.	Advanced interpersonal skills for collaborating effectively with all levels of clinical and technical staff and representatives of external regulatory agencies and for mentoring lower-level QI staff.	Highly developed interpersonal skills for collaborating effectively with all levels of clinical and technical staff and representatives of external regulatory agencies, and for mentoring and training lower-level QI staff.
KSA 06	Basic ability to effectively communicate both verbally and in writing, and the ability to contribute to clear and concise reports, presentations, and documentation.	Demonstrated ability to effectively convey complex clinical and technical information both verbally and in writing, and to produce reports, presentations and documentation.	Strong skills required to effectively convey complex clinical and technical information both verbally and in writing and to produce high quality reports and documentation.	Advanced ability to effectively convey complex clinical, technical, and educational information both verbally and in writing, and to produce high quality reports, documentation, and presentations.	Highly developed ability to effectively convey complex clinical, technical, and educational information both verbally and in writing, and to produce high quality reports, documentation, and presentations.
KSA 07	Basic knowledge of various administrative and business software packages.	Working knowledge of various administrative and business software packages, and of the specialized applications for quality data management.	Strong knowledge of various administrative and business software packages, and of the specialized applications for quality data management.	Advanced knowledge of various administrative and business software packages, and of the specialized applications for quality data management.	Expert knowledge of various administrative and business software packages, and of the specialized applications for quality data management.
KSA 08			Strong skills to influence staff, management, and clinicians at all levels and across departments.	Advanced skills to influence and persuade staff, management, and clinicians at all levels and across departments.	Expert ability to collaborate effectively with staff, management, and clinicians at all levels and across departments.
Environment	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)