Quality Manager - Pediatric Perioperative Services

The BCH Pediatric Perioperative Services Quality Manager provides strategic and operational leadership for multidisciplinary pediatric surgical programs, ensuring alignment with ACS Children''s Surgery Verification Level 1 standards. This role leads the planning, development, and oversight of pediatric perioperative services, driving continuous improvement and high-quality patient care. This role leads the planning, development, and oversight of pediatric perioperative services, driving continuous improvement and supporting high-quality, patient-centered surgical care.

Determines department objectives in accordance with overall strategic plan. Erroneous decisions or failure to adhere to objectives results in additional costs and serious delays in overall schedules.

Maintains 24-hour accountability for fiscal, material, and human resources, including supervision of leader-level direct reports, and advances performance through collaboration, data-driven decision-making, and continuous improvement.

Required Qualifications:

• Minimum of 8 years'' experience in a children''s hospital setting with a surgical or critical care focus
• Bachelor''s degree in nursing or a healthcare profession
• Demonstrated hospital management skills with expertise in quality improvement, statistical analysis, and database management
• Proven ability to organize, manage priorities, meet deadlines, and assign work efficiently
• Demonstrated leadership, fiscal and operations management skills, with the ability to collaborate effectively with physicians, management and staff at all levels, and external agencies
• Strong critical thinking and problem-solving skills, with the ability to quickly identify problems and implement solutions
• Demonstrated knowledge of relevant healthcare information technology and clinical QI workflows and processes
• Demonstrated knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments
• Highly developed interpersonal skills to foster effective communication, collaborative decision-making, and strong working relationships across all levels of clinical and technical staff, external regulatory agencies, and quality improvement teams, including mentoring and training of QI staff
• Ability to create and maintain a goal-oriented climate of teamwork, collaboration and consistent achievement of objectives
• Knowledge of relevant healthcare information technology and patient care workflows and processes. Advanced knowledge of various administrative and business software packages, and of specialized applications for quality data management

Preferred Qualifications:

• Master''s degree in Nursing or relevant area
• Certification in relevant area

Required License/Certifications:

• Registered Nurse in the State of California
• Serve as an expert resource and provide clinical supervision for pediatric surgical practice across BCH Oakland and San Francisco.
• Lead and coordinate team performance to achieve organizational goals, spending the majority of time on administrative tasks.
• Maintain accountability for unit operations, including fiscal, capital, and human resource management, ensuring cost-effective performance.
• Implement policies and procedures for coordination of care across various patient populations, partnering with managers from different services.
• Develop staff in collaborative decision-making and shared governance, creating an environment for improved nursing and patient care outcomes.
• Manage employee recruitment, performance evaluation, discipline, and staff development, fostering a strong culture of teamwork.
• Work collaboratively with labor relations on bargaining unit issues and contract negotiations at the local level.
• Develop relationships with clinical departments and provide training to integrate quality and safety across the clinical enterprise.
• Facilitate and oversee resolution of HR, labor relations, employee safety, and risk management issues.
• Ensure compliance with accreditation and licensure requirements, working with colleagues to maintain a compliant clinical services environment.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

50

Yes

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%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

• Serve as an expert resource and provide clinical supervision for pediatric surgical practice across BCH Oakland and San Francisco.
• Lead and coordinate team performance to achieve organizational goals, spending the majority of time on administrative tasks.
• Maintain accountability for unit operations, including fiscal, capital, and human resource management, ensuring cost-effective performance.
• Implement policies and procedures for coordination of care across various patient populations, partnering with managers from different services.
• Develop staff in collaborative decision-making and shared governance, creating an environment for improved nursing and patient care outcomes.
• Manage employee recruitment, performance evaluation, discipline, and staff development, fostering a strong culture of teamwork.
• Work collaboratively with labor relations on bargaining unit issues and contract negotiations at the local level.
• Develop relationships with clinical departments and provide training to integrate quality and safety across the clinical enterprise.
• Facilitate and oversee resolution of HR, labor relations, employee safety, and risk management issues.
• Ensure compliance with accreditation and licensure requirements, working with colleagues to maintain a compliant clinical services environment.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

50

Yes

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%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)