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PI Supervisor

Chinese Hospital

845 Jackson St, San Francisco, CA 94133

About this role

Department: PI, Safety, Compliance & Risk Management
Reports to: Director of Quality and Risk Management
Type: Full time
Requisition#: 12209

Position Summary

The Performance Improvement Supervisor role is responsible for leading the Performance Improvement staff in the delivery of core processes designed to improve quality and efficiency in the care of our patients and meet contractual obligations to our partners and prepare and maintain the organization for accreditation and licensure.

Essential Duties and Responsibilities

  • Leads, coordinates, and monitors the review and analysis of performance improvement projects and core measures, ensuring The Joint Commission (TJC), Title 22, and CMS compliance.
  • Supervises the team in the coordination of peer review activities, submission of quality data to external entities such as but not limited to The Joint Commission, and CMS.
  • Provides staff support in the development, implementation and evaluation of Chinese Hospital’s performance improvement methodology and regulatory survey readiness activities
  • Coordinates and staff medical physician department / committee meetings as assigned.
  • Prepares correspondence, statistical reports, Policies and Procedures, Protocols, and Department PI Plans.
  • Assists with the coordination of unannounced state/federal/and any other mandated hospital surveys.
  • Coordinates and implements robust communication and education program related to readiness activities including tracer activities, survey methods and processes, results of compliance assessment activities, and methods of compliance for problematic and high-priority requirements.
  • Assists with core measure, FMEA process projects, and other Medical Staff related activities such as OPPE/FPPE, etc.
  • Follows Hospital and Department policies and procedures at all times, including but not limited to: Administrative Manual, Environment of Care, Human Resources, Infection Control, Corporate Compliance, Code of Ethics, etc.
  • Attends and actively participates and completes in-services, training classes, mandatory classes, seminars/workshops, staff meetings, exercises and drills; reads all department communication and assigned materials.
  • Customer Service – Provides excellent customer service and shows compassion to all patients, visitors and co-workers. Seeks feedback to ensure all needs are met. Anticipates and recognizes the concerns of others, even if those concerns are not openly expressed.
  • Communication – Keeps manager and team informed of progress, problems, development and plans. Gets along and interacts positively with co-workers and others.
  • Accepts and performs other duties as assigned.



  • Knowledge of ongoing monitoring techniques (including Hospital’s performance improvement methodology).
  • Strong and effective communication and, as well as computer literacy are a must.
  • Bachelor’s Degree in Healthcare preferred.
  • CPHQ preferred
  • 3 years+ of healthcare experience in performance improvement activities and regulatory surveys.
  • Demonstrated ability to develop, organize, and facilitate special quality improvement projects
  • Familiarity with accreditation standards and survey process (i.e., the Joint Commission Standards for Accreditation of Hospitals, California Code of Regulations Title 22, CMS Conditions of Participation for Hospitals)
  • Demonstrates knowledge of principles related to quality and performance improvement, current knowledge of Joint Commission standards, California Administrative Code, Title 22 licensing requirements, CMS standards, and medical staff peer review
  • Ability to work collaboratively with physicians, hospital staff, and external organizations
  • Excellent analytical, project management and independent problem-solving skill


  • Progressive recent experience in quality assessment and improvement management desirable.
  • Proven ability in working with complex multi-disciplinary teams in regards to communication and teamwork.
  • Demonstrated ability in writing and presentation skills.

Physical Requirements

While performing the duties of this job, staff is regularly required to sit, stand, walk, talk and/or listen. He/she uses his/her hands to do computer work, write reports, do equipment set-up/cleaning/storage, clerical support, etc. He/she will be using the phone frequently. Good vision is needed to be able to read schedules, enter accurate data, etc. He/she must have good general health and demonstrate emotional stability so as to carry out the above-enumerated duties.

  • Able to lift up to 30 pounds
  • Use proper body mechanics when handling equipment
  • Standing, walking and moving 50% of the day

Compliance Requirements

Complies with Chinese Hospital Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.


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