FACT Quality Specialist (1.0 FTE, Days)

Category: Quality
Job Type: Part-Time
Shift: Days
Req: 13574
FTE: 1


1.0 FTE, 8 Hour Day Shift

At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

This paragraph summarizes the general nature, level and purpose of the job.

The Foundation for Accreditation of Cellular Therapy (FACT) Quality Specialist provides project management and facilitation and oversight/support for the development, coordination, implementation and evaluation of quality and performance improvement, patient safety, and clinical effectiveness initiatives within the Stem Cell Transplant (SCT) & Pediatric Center for Cancer Cell Therapy (PCCTC)  Influences clinical processes, systems, and outcomes and acts as an internal consultant for the SCT & PCCTC program providing team facilitation, leadership, coaching, change management, and process improvement.  Scope includes inpatient and outpatient clinical programs within Lucile Packard Children's Hospital's network.


Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification.  They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities.  Employees may also perform other duties as assigned.

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the hospital’s policies and procedures, including its Service Standards and its Code of Conduct.


  • Performs data analysis; creates & interprets data displays, including clinical, cost, and patient satisfaction data. Works collaboratively with Information Technology (IT) Informatics team, Finance, Enterprise Data Warehouse/Clinical Business Analytics, and others to ensure the integrity and accuracy of the data that is utilized. Performs data analysis to assure program exceeds LPCHS and SOM quality metrics.


  • Acts as a consultant to ensure quality systems are in place in all areas of the program, including Cellular Therapy Facility, Apheresis and marrow collection.


  • Evaluates data, makes judgments, and provide recommendations regarding quality improvement work.


  • Coordinates with the medical directors on the regular reporting of BMT and CCT quality data to the appropriate hospital committees. Prepares or assists with the presentations for those meetings.


  • Organizes, facilitates, and leads multi-disciplinary teams to successfully implement performance improvement initiatives to achieve program quality improvement goals.


  • Annually coordinates a review of the Performance Improvement indicators defined for each program and makes recommendations for revisions.


  • Oversees the ongoing medical record reviews. Collates and submits data related to these reviews to the leadership team and hospital departments as requested.


  • Facilitates value stream mapping and identifies and leads efforts to improve value.


  • Maintains current knowledge of requirements related to The Joint Commission, FACT and National Marrow Donor Program (NMDP), Center for International Blood and Marrow Transplant Research (CIBMTR) and facilitates and coordinates accreditation and regulatory compliance.


  • Provides regular updates to managers and ongoing education to staff as requested by the management staff.


  • Responsible for supporting management staff in achieving and maintaining accreditation and regulatory compliance within SCT & PCCTC Program.


  • Prepares and maintains materials/documents used for surveys and audits assists managers and staff in ensuring continuous readiness for survey with policy and procedure review and revision, mock survey drills, and ongoing education.


  • Coordinates scheduling of announced visits/surveys. Coordinates preparation of FACT reports including annual report. Alerts the management team if there is not full compliance with the requirements.


  • Provides leadership for creating a culture of patient safety and works with various constituencies to ensure compliance to the National Patient Safety Goals. Ensure compliance with internal and external patient safety goals.


  • Facilitates root cause analysis and critical incident reviews. Ensures action items are completed on time.


  • Identifies trends in iCARES Event reports and recommends action plans. Partners with SCT, Center for Definitive and Curative Medicine (CDCM) and PCCTC in addressing adverse events related to systems issues.


Minimum Qualifications

Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.


Education:  Bachelor's degree in a relevant field or discipline (for example, Healthcare Management, Biology, Public Health, Nursing, or Business Administration).


Experience: Five (5) years of progressively responsible and directly related work experience in quality improvement, patient safety, and external regulatory/accrediting agencies compliance activities in support of improving clinical effectiveness and patient care/outcomes.




 Knowledge, Skills, & Abilities


These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.


  • Knowledge of the principles and practices of quality improvement, including, in particular, their application in an academic medical center.


  • Knowledge of and ability to apply multiple performance improvement methodologies and tools to projects (e.g. Lean, Six Sigma, FMEA, Poka-Yoke, 5S, SIPOC, value stream mapping, process mapping, cause and effect diagrams, prioritization and selection matrix).


  • Knowledge of advanced quantitative skills and ability to use statistics to evaluate and interpret data, summarize results and make recommendations.


  • Knowledge of project management and change management methodologies and tools.


  • Knowledge of the principles and practices of supervision.


  • Knowledge and proficiency in the use of the Microsoft Office Suite of applications, clinical documentation systems (preferably EPIC), as well as decision support systems.


  • Ability to utilize the Clinical Effectiveness framework to ensure that performance improvement initiatives focus on improving outcomes, appropriateness of care, patient centeredness, and value.


  • Ability to lead multi-disciplinary teams through Kaizens/RIE/RPIW.


  • Ability to coordinate project initiatives, meetings, and clinical program management to achieve service and unit specific goals and strategic direction. 


  • Ability to understand and use structure to drive process changes and how to use processes to drive towards desired outcomes.


  • Ability to plan, organize, direct and evaluate the work of others.


  • Ability to work collaboratively in a multi-disciplinary environment.


  • Ability to demonstrate sound judgment and reasoning.


  • Ability to understand and use information technology to drive process changes.


  • Ability to influence effectively to create synergy prioritizes projects, set goals and actions plans, and measure impact.


  • Ability to stay abreast of quality measures receiving external visibility and attention (e.g. CMS, HealthGrades, US News & World Report).


Physical Requirements


The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job



Equal Opportunity Employer

Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.