Quality Improvement Specialist

City of Hope

Duarte, CA

Job posting number: #7125876 (Ref:10019250)

Posted: March 29, 2023

Salary / Pay Rate: $48.30 - $77.28 / hour

Application Deadline: Open Until Filled

Job Description

About City of Hope

City of Hope is an independent biomedical research and treatment organization for cancer, diabetes and other life-threatening diseases.

Founded in 1913, City of Hope is a leader in bone marrow transplantation and immunotherapy such as CAR T cell therapy. City of Hope’s translational research and personalized treatment protocols advance care throughout the world. Human synthetic insulin, monoclonal antibodies and numerous breakthrough cancer drugs are based on technology developed at the institution. AccessHope™, a subsidiary launched in 2019 serves employers and their health care partners by providing access to City of Hope’s specialized cancer expertise.

A National Cancer Institute-designated comprehensive cancer center and a founding member of the National Comprehensive Cancer Network, City of Hope is ranked among the nation’s “Best Hospitals” in cancer by U.S. News & World Report and received Magnet Recognition from the American Nurses Credentialing Center. Its main campus is located near Los Angeles, with additional locations throughout Southern California and in Arizona.

City of Hope’s commitment to Diversity, Equity and Inclusion

We believe diversity, equity and inclusion is key in serving our mission to provide compassionate patient care, drive innovative discovery, and advance vital education focused on eliminating cancer and diabetes in all of our communities. Our commitment to Diversity, Equity and Inclusion ensures we bring the full range of skills, perspectives, cultural backgrounds and experiences to our work -- and that our teams align with the people we serve in order to build trust and understanding. We are dedicated to fostering a community that embraces diversity - in ideas, backgrounds and perspectives; this is reflected in our work and represented in our people.

Position Summary

This role acts as a consultant, empowering others across the Enterprise to meet their needs for data and performance improvement support. The position supports the Enterprise by providing data, analysis, best practice and background information to the organization and the Medical Departments, for performance improvement activities, quality reports and support for peer review. The Quality Improvement Specialists (QIS) also support regulatory and accreditation activities. This position is designed to assist the organization in defining, measuring, analyzing, and applying data to make quality improvements and comply with accreditation standards and/or regulations. The QIS is an expert resource in process and outcome measurement, analysis, and performance improvement including concepts and techniques, evidenced based practices, relevant legislation, accreditation standards, medical staff bylaw/rules and regulations, and policies/procedures. The position requires knowledge of lean/six sigma process improvement tools, facilitative leadership, change management and regulatory and licensing standards.

Key Responsibilities include:

Team Leading/Facilitation

  • Coordinates and leads discrete quality improvement teams in collaboration with each team’s physician liaison.
  • Collaborates with administrators and/or the physician liaison for each team in the development of the agendas; tracks the actions, and assures timely follow up on actions.

Event Investigation, Mitigation and Correction

  • Supports event reporting and peer review for campus and external community clinics.
  • Facilitates root cause analyses and other investigative activities needed to refine and modify policies and procedures and/or processes to improve the quality of patient care.
  • Follows-up on quality activities such as case/sentinel event reviews to make sure appropriate changes have taken place.

Quality/Metric and Peer Data Collection and Reporting

  • Obtains, reviews and analyzes clinical data through review of the in-patient and out-patient medical record and data reports from numerous sources to gather data for OPPE, peer review, other case review, quarterly quality reports, special projects, performance improvement and other quality metrics chosen by the organization or mandated by external agencies;
  • Participates in observational activities (e.g. nursing studies, policy adherence) to collect needed data.
  • Collaborates with Quality Analytics, Biostatistics and other departments to develop processes to ensure accurate, timely, consistent access to relevant data.
  • Presents data in a meaningful and useful manner.
  • Attends the applicable medical staff committees for quality report and event review and is an active participant at QA&I;

Performance Improvement

  • Acts as an expert internal consultant for performance improvement activities including the Performance Excellence Program.
  • Uses data in recommending solutions to issues,
  • Utilizes change theory and systems analysis to impact improvements in practice or standards compliance.
  • Models behaviors that support improvement activities including critical thinking and multiple strategies identification.
  • Coaches and supports staff in using performance improvement strategies in their work.
  • Supports physicians and staff to make recommendations and identify performance improvement opportunities based on data.
  • Incorporates improvement strategies to enhance quality of patient care.

Accreditation and Survey Readiness

  • Active member of the CALS Committee.
  • Coordinate monthly tracers with team leads and collects all data related to tracer activities for corrective action.
  • During actual surveys (Joint Commission, CDPH, CAP) act as scribes and escorts
  • to the survey team and staff, the command center.

Regulatory/Compliance

  • Demonstrates knowledge of regulatory bodies and standards as they apply to their areas of responsibility
  • Identifies the need to develop or revise policies/procedures as they relate to quality work.
  • Keeps the medical staff and other committees informed on the metric teams, and solicit ongoing input to drive improvements.
  • Demonstrates understanding and support the Code of Conduct.

Education and Teaching

  • Supports education that impacts quality of patient care, reduces risk, and promotes regulatory readiness.
  • Provides management with information regarding the Clinical Quality and Healthcare Improvement Program.
  • Assists with education of staff as requested
  • Attends mandatory and non-mandatory medical center, divisional, and departmental education activities

Collaboration and Teamwork

  • Supports and facilitates positive working relationships within the department, between individual employees and other healthcare providers.
  • Supports team working relationships within assigned department(s) between all levels of personnel
  • Works with director to facilitate conflict resolution interdepartmentally and between employees
  • Serves as a role model to staff and other by demonstrating collaborative working relationships with employees and all patient care departments
  • Facilitates positive relationships for those requesting departmental assistance
  • Maintains effective open communication between departments in order to assure timely and quality care for patients/families
  • Facilitates and support working relationships with patients, families, or other health care providers
  • Identifies and participates in the resolution of breaks in communication between parties
  • Promotes positive interpersonal relationships and demonstrates effective communication methods
  • Maintains awareness of and follows appropriate lines of communication
  • Facilitates staff in utilization of appropriate lines of communication

Professional Development

  • Maintains professional code of ethics and scope of practice by adhering to national, institutional, and divisional standards, policies, procedures, and protocols.
  • Participates in appropriate professional organizations
  • Maintains current licensure and certifications
  • Demonstrates accountability and responsibility for own professional practice
  • Attends organization wide and medical staff committees as assigned
  • Attends at least 70% of assigned meetings
  • Maintains awareness of own developmental needs
  • Shares new knowledge with other member of the staff and colleagues
  • Incorporates knowledge and skills into professional practice and program development.
  • Utilizes networking to obtain relevant information in the understanding and application of relevant practice and regulatory standards

Performs other duties as assigned

Basic education, experience and skills required for consideration:

  • Masters Degree in Nursing or BSN with masters in related/complementary field required. Experience may substitute for minimum education requirements.
  • Three years experience in clinical nursing and/or quality, risk and regulatory activities
  • Thorough knowledge of Joint Commission, Title 22, CMS Conditions of Participation and other regulatory agencies

Required Certification/Licensure:

  • Current California RN license
  • Specialty certification (CPHQ/HACP) preferred

Additional Information:

  • Job Status: Full-time, exempt
  • As a condition of employment, City of Hope requires staff to comply with all state and federal vaccination mandates.

Salary / Pay Rate Information:
Pay Rate: $48.30 - $77.28 / hour

The estimated pay scale represents the typical [salary/hourly] range City of Hope reasonably expects to pay for this position, with offers determined based on several factors which may include, but not be limited to, the candidate’s experience, expertise, skills, education, job scope, training, internal equity, geography/market, etc. This pay scale is subject to change from time to time.



City of Hope is a community of people characterized by our diversity of thought, background and approach, but tied together by our commitment to care for and cure those with cancer and other life-threatening diseases. The innovation that our diversity produces in the areas of research, treatment, philanthropy and education has made us national leaders in this fight. Our unique and diverse workforce provides us the ability to understand our patients' needs, deliver compassionate care and continue the quest for a cure for life-threatening diseases. At City of Hope, diversity and inclusion is a core value at the heart of our mission. We strive to create an inclusive workplace environment that engages all of our employees and provides them with opportunities to develop and grow, both personally and professionally. Each day brings an opportunity to strengthen our work, leverage our different perspectives and improve our patients’ experiences by learning from others. Diversity and inclusion is about much more than policies and campaigns. It is an integral part of who we are as an institution, how we operate and how we see our future.


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