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Job Description
Under the general direction of the Vice President for Quality and Patient Safety the Senior Director for Quality & Patient Safety Saint Francis (SF) and St. Marys (SM).
provides strategic direction executive level leadership planning organization and general management for all aspects of the SFs and SMs Quality & Patient Safety program. This highly visible and matrixed senior leadership role will partner with the SF and SM executive team the UCSF Health Quality and Patient Safety executive team and other key partners (e.g. physician leaders UCSF Health leaders affiliates/partners etc. to develop and execute a strategy for Quality and Patient Safety across the SF and SM enterprise. The incumbent is responsible for meeting or exceeding the institutional goals set for Quality & Patient Safety across SF and SM and to external reporting bodies.

Specific areas of responsibility include the following:

• SF and SM Quality Improvement (across spectrum of care at UCSF Health Community Hospitals)
• Patient Safety
• Regulatory Compliance in partnership with UCSF Health Director of Regulatory Affairs
• Hospital Epidemiology & Infection Control (HEIC)
• Data Analytics
• Patient Experience in partnership with UCSF Health Division Director of Experience
• Quality and Regulatory for 20 outpatient departments:
  • MACRA/MIPS quality measure & submission
  • CLIA licenses
  • SF city business licenses
• Outpatient Prospective Payment System (OPPS) management
• RAC audits (Reduction Recovery Audits)
• Onsite Payor audits for clinics (i.e. BCBS)
• CMS STARs rating review & analysis and action planning
• Accreditation programs/surveys not covered by Regulatory:
• CEEP School (Counseling Enriched Education Program)
  • San Francisco Department of Public Health Community Behavioral Health Services annual program audit
• College of American Pathologists/ Laboratory (CAP)
• Surgical Review Corporation for Transgender Program
• American Burn Association Burn Center Verification ICU Burn Unit
• San Francisco Department of Public: Business Office of Contract Compliance for Integrated HIV Services Review
• California Department of Public Health Infectious Disease Bureau
• Diabetes SelfMgmt Training (DSMT) entity Audit (CMS via IMS)
• Commission on Accreditation of Rehabilitation Facilities (CARF)
• Inpatient Diabetic Nurse Educator (review hypoglycemia episodes diabetic champions etc)
• Orthopedic Service Line
  • IPPS
  • CMS Core Measures
• Leapfrog Survey

The final salary and offer components are subject to additional approvals based on UC policy.

Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union placement within the salary range will be guided by the rules in the collective bargaining agreement.

The salary range for this position is $144200 $350000 (Annual Rate).

To learn more about the benefits of working at UCSF including total compensation please visit: degree in nursing or other healthcare profession or a combination of comparable clinical education and / or experience

Advanced degree in Nursing or related Health Care field (e.g. MPH MBA MHA etc. or an equivalent combination of education and experience

At least 5 years of increasingly responsible management and leadership experience in a large academic medical center and/or a large medical center with a proven track record in quality improvement program development and related planning (ideally in a multisite hospital system)

Strong hospital management experience with progressive and indepth expertise in quality and process improvement methodologies statistical analysis and data base management

Strong organizational and leadership skills to solve complex issues

Must communicate with impact to build and maintain a climate of trust

Must interact and negotiate in a professional manner with a variety of highly influential entities including the Chancellor and Campus Senior Leadership UCSF Health and School of Medicine Leadership major donors/members of the UCSF Foundation Congressional and Legislative offices UCOP Deans Department Chairs Chiefs (e.g. CMO CNO CIO) and Faculty and Department and Clinical Managers

Advanced analytical organizational and problemsolving skills with indepth ability to develop and pursue goals synthesize data to identify system vulnerabilities and develop and apply innovative solutions

Astute in hospital finance and information systems; business acumen and analytic skills

Excellent skills in developing strategic plans creating benchmarks integrating programs building staff competencies organizing operations and fiscal management

Excellent leadership and fiscal management skills with the ability to create a goaloriented climate of teamwork collaboration and consistent achievement of objectives

Demonstrated leadership/management skills and excellent interpersonal relationship skills

Proven track record in recruitment retention and development of talent

Strong ability to work collaboratively and effectively with medical staff nursing leadership ancillary departments and staff

Commitment to an academic mission which supports education research and staff development

This position requires flexibility to orient and work at all UCSF Health locations as needed

• National specialty certification (e.g. CPHQ CCDS NEABC CENP)
• Experience with LEAN methodologies and/or knowledge and support of LEAN principles
• Previous executive level experience
• Strong knowledge of relevant healthcare information technology including QI workflows and processes relevant systems and data management techniques and methodologies
• Strong knowledge of relevant QI regulatory requirements as well as related legislative accreditation licensing and compliance environments

Equal Employment Opportunity
The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability age protected veteran status or other protected status under state or federal law.

Department Description
The Department of Quality & Safety consists of Adult Quality & Safety Benioff Childrens Hospitals (BCH) Quality & Safety Saint Francis and St. Marys Quality and Safety Hospital Epidemiology & Infection Prevention Regulatory Affairs Health Equity Clinical Documentation Integrity and Risk. The teams are made of multidisciplinary professionals with diverse backgrounds. The role of the Department is the support UCSF Health to deliver safe equitable and highquality care to the communities we serve.


About UCSF
At UCSF Health our mission of innovative patient care advanced technology and pioneering research is redefining whats possible for the patients we serve a promise we share with the professionals who make up our team.

Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth UCSF Health offers the ideal atmosphere in which to best use your skills and talents.

Pride Values
UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism respect integrity diversity and excellence also known as our PRIDE values.

In addition to our PRIDE values UCSF is committed to equity both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community nurturing a culture that is welcoming and supportive and engaging diverse ideas for the provision of culturally competent education discovery and patient care. Additional information about UCSF is available at

Join us to find a rewarding career contributing to improving healthcare worldwide.