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Quality Improvement Coordinator - Custody Health Services - Extra Help

Under direction, to plan, coordinate, and implement quality improvement activities as required by various regulatory bodies, such as State, Federal, and The Joint Commission (TJC) regulations and requirements for the County of Santa Clara Health System (CSCHS).

Custody Health Services is currently recruiting for two (2) Quality Improvement Coordinator - Extra Help position.

Custody Health Services (CHS) provides medical, mental health, and dental services to patients in custody at the four County detention facilities: Main Jail, Elmwood, Juvenile Hall, and James Ranch. On-site routine and urgent/emergent medical services are provided at both Main Jail and Elmwood adult jail facilities in Santa Clara County. Health care of incarcerated patients includes care of acute and chronic illness as well as preventative and specialty care. CHS also operates a 40-bed acute psychiatric inpatient housing unit at the Main Jail facility for incarcerated adults who require acute inpatient services for stabilization. Juvenile Custody Health Services provides integrated medical services including comprehensive pediatric medical, mental health, and dental care to justice-involved youth housed in Juvenile Hall and James Ranch.

Selected candidate(s) must be able to work in a correctional facility, which requires passing a background check for security clearance.

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Requirements

The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Each individual in the classification does not necessarily perform all duties listed.

  • Monitors the County of Santa Clara Health System departments to ensure compliance with the Quality Improvement Plan;
  • Coordinates division and department quality improvement activities, including surveys and audits;
  • Ensures that standards, policies, and procedures are consistent with professional standards and requirements as defined by various regulatory bodies;
  • Assesses quality improvement training needs; plans, implements, and/or coordinates training for staff;
  • Participates in organizational and departmental committees and task forces;
  • Participates in developing systems and procedures to meet the internal goals and objectives of the Quality Improvement Plan;
  • Conducts and supports investigations with medical, nursing, and other staff;  plans quality improvement activities to resolve identified problem areas;
  • Maintains current knowledge of organizational goals and objectives;
  • Promotes and facilitates process/quality improvement activities within the Health System;
  • Collaborates with various stakeholders  regarding organizational standards, policies, and procedures;
  • Initiates changes in standards, policies, procedures, and practices based on quality improvement review;
  • Interprets policies and regulations to medical, nursing, and professional support staff;
  • Promotes compliance with legal and regulatory requirements;
  • Plans accreditation and regulatory surveys; prepares responses/reports based on reports of findings;
  • Works to mitigate organizational and patient safety risks and collaborates with Risk Management staff regarding risk/quality issues;
  • Identifies local and national trends applicable to quality improvement standards;
  • Evaluates the feasibility of new programs to enhance compliance with standards;
  • Acts as a resource for quality improvement activities;
  • Performs concurrent and retrospective chart reviews and analysis for selected department and organizational indicators;
  • Collaborates with staff from medicine, nursing, and other professional support staff in the development, implementation, and evaluation of Patient Care Guidelines; may collaborate with medical staff for peer review and quality support, when indicated;
  • Initiates and participates in research related to standards, quality improvement, and risk management; utilizes research to support changes of standards and practice;
  • May be assigned as a Disaster Service Worker (DSW), as required*;
  • Performs other related duties, as required.

Qualifications

Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, plus the possession and direct application of the following knowledge and abilities:

Training and Experience Note:  The required knowledge and abilities are attained through four (4) years of full-time Registered Nursing (RN) experience in an accredited hospital, clinic, and/or healthcare setting. 

Nursing management experience is desirable but not required.

Special Requirements

  • Possess and maintain an active California Registered Nurse license, without restrictions, for the duration of employment in this classification.
  • Ability to travel to alternate locations in the course of work.  If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization.
  • *As a condition of employment, pursuant to California Government Code Sections 3100-3109 and Local Ordinance, all County of Santa Clara employees are designated Disaster Service Workers (DSWs), including extra help.  A DSW is required to complete all assigned DSW-related training, and in the event of an emergency, return to work as ordered.

Knowledge of:

  • Hospital, outpatient, or location-specific healthcare organizations, operations, and procedures;
  • Federal and State healthcare laws and regulations common to the operation of hospitals in California and/or laws applicable to the healthcare setting;
  • Regulations of intermediary agencies pertaining to hospital stay coverage (e.g., Medicare and MediCal);
  • Quality improvement and risk management standards, policy, procedures, and protocols;
  • Current trends, issues, and research in Quality Improvement in large medical services systems;
  • Standards, policies, procedures, and medical protocols in a healthcare setting;
  • The Joint Commission standards and Title XXII requirements and Federal regulations;
  • Regulatory requirements for acute care hospital, ambulatory, or applicable healthcare settings;
  • Medical terminology and related levels of care and treatment;
  • Methods, regulations, and procedures for research within a healthcare setting;  
  • Evaluation and assessment techniques;
  • Record keeping and reporting procedures;
  • English usage, style, grammar, punctuation, and spelling;
  • Common computer systems and applications.

Ability to:

  • Analyze data, write reports, identify trends and appropriate corrective action plans, and evaluate improvement programs and activities;
  • Evaluate and interpret complex medical regimens pertaining to quality-of-care standards;
  • Plan, develop, and organize work;
  • Communicate effectively, both orally and in writing, with people of diverse backgrounds and cultures;
  • Develop personal and professional quality improvement goals;
  • Facilitate quality improvement teams to implement quality improvement goals and standards;
  • Work effectively and manage multiple projects with minimal supervision;
  • Manage multiple conflicting priorities while demonstrating strong organizational and leadership skills; 
  • Plan and implement quality improvement educational activities for medical, nursing, and professional support staff;
  • Maintain current knowledge of trends/practices in quality management;
  • Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and representatives of other agencies.
Date Posted
05/04/2026
Job Reference
26-ED1-A
Organization
Santa Clara Valley HHS - Custody Health Services, CSCHS Administrative Services
Location
Santa Clara, CA 95050
Category
Allied Health
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