Quality Manager - Pediatric Perioperative Services

% 

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

50

Administrative:

• Serves as an expert resource for pediatric surgical clinical practice and provides clinical supervision to Children’s Surgery Program and quality nursing staff across BCH Oakland and San Francisco, including Children’s Surgery Program Manager, Process Improvement Nurses, and NSQIP Pediatric Surgical Clinical Reviewers.
• Spends the majority of time leading and coordinating team performance to achieve organizational goals. 
• Maintains 24-hour accountability for unit operations, including fiscal, capital, and human resource management, ensuring cost-effective performance aligned with organizational objectives. Manages a unit in a cost-effective manner, consistent with the financial goals of the organization. Plans and are accountable for the annual operating and capital budget for areas of responsibility.
• Partners with managers across services (e.g., outpatient, children's, cancer center, etc.) to implement policies and procedures for coordination of care for all patient populations.
• Develop staff in collaborative decision making and shared governance. Creates an environment for a shared voice in nursing practice and the exchange of ideas to continually improve nursing and patient care outcomes.
• Responsible for employee recruitment, performance evaluation, progressive discipline, and staff development. 
  • Develops a strong culture of teamwork to ensure the quality of daily operations, effective interdepartmental collaborations, and the timely achievement of objectives. 
  • Determines staffing needs and plans. 
• Works collaboratively with labor relations on bargaining unit issues and contract negotiations at the local level. 
• Develops relationships with clinical departments and provides training to facilitate the integration of quality and safety to benefit the overall clinical enterprise.
• Facilitates and oversees resolution of human resources, labor relations, employee safety and risk management issues.
• Works with colleagues across the medical center to ensure compliance with accreditation and licensure requirements with the clinical services environment, including JCAHO, CMS, and State of California.

25

Program Leadership:

• Leads efforts to achieve and maintain ACS Children’s Surgery Verification across UCSF Benioff Children’s Hospitals, ensuring compliance with all regulatory standards. Integrates clinical initiatives, data abstraction, and patient safety efforts, and leads monthly Perioperative Performance Improvement & Patient Safety (PIPS) committees and PIPS Subcommittees. Develops tools and processes to monitor and sustain program compliance.
• Prepares UCSF Benioff Children’s Hospitals, and other related departments, for verification and re-verification on-site or virtual site visits as indicated by the American College of Surgeons, including:
  • Securement of budgetary needs.
  • Coordination with administrative staff on conference space booking, site visit agendas, and ACS reviewer travel.
  • Creation of materials for all aspects of the site visit.
• Works collaboratively with the Medical Directors of the Children's Surgical Program, the Medical Directors of Children’s Anesthesia, the NSQIP Surgeon Champion.
• Attends and represents and the BCH programs at the annual ACS Quality, Safety & Cancer Conference.

10

Consultant and Liaison:

• Represents the department on interdisciplinary committees addressing patient experience, quality improvement, workflow efficiency, and clinical systems. Serves as a key liaison and internal resource, coordinating across multiple disciplines to support high-quality pediatric surgical care.
• Stabilize the complex network of many disciplines that work in concert to provide high­ quality children’s surgical care. Serve as an internal resource for staff in all departments and act as an extended liaison for other system entities. 
• Builds and maintains partnerships with professional organizations, peer programs, and referring institutions to share best practices and resources. Represents the program at regional and national forums, including invited presentations.

10

Data & Reporting:

• Oversees processes for the collection, validation, analysis, and reporting of data to meet ACS requirements. Supervises and leads quality improvement reviews of key events (e.g., mortality, sentinel events, readmissions), ensuring timely review and integration of findings into departmental QI plans. Supervises NSQIP Pediatric Surgical Clinical Reviewers to ensure accurate data abstraction and reporting.
• Works with IT managers to plan and implement new or improved patient care information systems.

5

Professional Development:

• Maintains competencies in professional field and stays up to date on latest literature.
• Attends conferences, training, or other learning opportunities, including a minimum of 16 hours (internal or external) of pediatric surgery-related continuing education per year.
• Pursues professional development and facilitates access to ongoing training, staff development, and educational opportunities for subordinate staff.
• Provides mentorship / leadership to new and emerging nurse leaders to smooth the transition from clinical roles to formal leadership roles. 
  • Educates on the business side of healthcare, while maintaining the care side. 

Reviews and approves individual leadership development plans and assists with identifying resources.

100%