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Quality & Patient Safety Analyst III

Job ID R-24124 Date Posted 03/28/2023 Location Burlingame, California Schedule/Shift/Weekly Hours Regular/Days/40


MPHS-Mills-Peninsula Medical Center

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Full Time

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Position Overview:

Responsible for developing new and implementing established processes for the measurement, analysis, and reporting of data. This individual will work with team members, end-users, and others to refine requirements, develop new or re-design, and deploy high-quality, accessible data queries and reports. Responsible for collecting, extracting and aggregating information from various Sutter Health system, hospital and/or ambulatory quality and financial data repositories and for performing analysis to provide meaningful information to clinical stakeholders. Maintains an existing report portfolio making modifications as requested. Responsible for the distribution of defined monthly, quarterly, annual and/or ad hoc reports/scorecards, meeting deadlines consistently. Provides expert database application management and technical support to systems. Troubleshoots advanced issues with these applications, seeking resolution using knowledge of the system or facilitating a solution with other Sutter teams. Conducts quality control checks and assures data quality and consistency. As applicable, supports the accurate and timely submission of data to the Office of Patient Experience and also to external benchmarking organizations (e.g., Centers for Medicare & Medicaid (CMS) Collaborative Alliance for Nursing Outcomes (CALNOC), National Healthcare Safety Network (NHSN), etc.).

Job Description:

These Principal Accountabilities, Requirements, and Qualifications are not exhaustive but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).


Provide Business Intelligence Solutions
• Develop, maintain and distribute data reports, scorecards, and dashboards while implementing advanced optimizations for quicker turn-around.
• Consult with customers and vendors to identify and resolve advanced problems, following through to ensure final resolution.
• Perform expert analysis on the existing reports before distribution to highlight changes in trends or variations.
• Areas of report responsibility may include but are not limited to Quality and Patient Safety, Comprehensive Health Assessment, and Infection Control.

Perform Data Analysis
• Elicit requirements from end-users in support of quality and safety initiatives. Lead improvement projects/programs as appropriate.
• Perform advanced analysis on the existing reports before distribution to highlight changes in trends or variations.
• Utilize an advanced understanding of statistical concepts to present or display data in a way that is end-user focused and accessible.
• Perform advanced-level extraction and aggregation from various data sources to highlight trends and gaps in care.
• Prioritize multiple defined projects or tasks to ensure on-time completion.

Support and Maintain Applications and Databases
• Troubleshoot advanced issues within database applications and modify existing dictionaries or settings based on changing requirements.
• Ability to perform data quality, data maintenance, and access provision with internal and external database applications as applicable to the ambulatory versus hospital setting.
• Develop and maintain a record of data collection methods, database structure, code, and analyses that is accurate, reliable, and accessible.
• Review and manage various system log files, error reports, alert audit logs, and security access logs, as assigned.
• Communicate key issues or incidents regularly to the immediate supervisor.

Process Improvement
• Work collaboratively with key stakeholders inside and external to the Quality and Safety Department to design and conduct performance improvement and outcomes studies.
• Utilize working knowledge of applications to drive process improvement and reduce waste through the use of standard work such as checklists and workflows.
• Maintain up-to-date knowledge of improvements and upgrades in relevant applications, SQL, and another appropriate programming language.
• Develop expert knowledge of application databases, desktop configuration, and application configuration for effective participation in all phases of project implementation and application support.

• Utilize independence and critical thinking to optimize existing data reports and/or scorecards.
• Take ownership of a project or task by handling time constraints and end-user expectations.
• Perform quality assurance techniques such as data accuracy checks via chart review and/or other methods
• Demonstrate a clear understanding of, and consistently adhere to, department policies and procedures in support of Sutter Health philosophies and initiatives.
• Integrate security practices in daily work by appropriately using and safeguarding protected health information (PHI) in compliance with Sutter Health HIPAA confidentiality and IT Security policies and procedures, rules, and regulations.

Professional Growth
• Documents and evaluates the attainment of personal performance goals that are relevant, measurable, and achievable.
• Identifies areas of further professional development and participates in activities that promote this growth.
• Collaborates with the Quality and Patient Safety Director to enrich personal/professional development as it relates to unit operations.

Other Responsibilities:
• Maintains a neat, clean professional appearance that is appropriate to job function and responsibilities.
• Maintains attendance and punctuality standards consistently and regularly.
• Demonstrates commitment to total quality management and customer service.
• Consistently utilizes time in an effective manner that addresses priority issues and meets established timelines.

Equivalent experience will be accepted instead of the required degree or diploma.

Bachelor's: Informatics, a health science-related field or another related field. or equivalent education/experience


A minimum of experience in SQL programming.

EPIC Clarity/ Cogito experience is preferred.


2 years' experience in SQL Query development

2 years' experience working in a healthcare setting.


Knowledge of database architecture and management and data extraction methods is required.

In-depth experience with Midas, including Quality, Risk, and Case Management modules, and/or Epic EHR or the equivalent.

Experience with Static PPR, Static PiMD, Tableau, Crystal Report Writer, and/or Allscripts.

Advanced SQL knowledge and experience.

Advanced skill with presentations, word processing, and spreadsheet applications with advanced knowledge of Microsoft Office Suite required.

Must be advanced in MS Excel.

Advanced analytical skills with the ability to collect, analyze, and disseminate significant amounts of information with attention to detail and accuracy.

Knowledge of health care operations, and health care (ICD 10, CPT, and/or DRG) coding with a focus on quality management and care coordination services in acute and non-acute outpatient settings. Includes structure, department-specific policies and procedures, and workflows.

Requires teamwork, organizational, and communication skills. ability to be involved in, and prioritize multiple projects at the same time in a rapidly changing environment is a must.

Must have the ability to interact with all levels of employees and medical staff as well as interface directly with external agencies and organizations.

Must have the ability to organize, interpret and present data effectively; creatively and effectively problem-solve, good decision-making skills.

Leadership, communication, and teaching/training skills.

Pay Range $47.89 - $71.83 / Hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.



Days of the Week:

Friday, Monday, Thursday, Tuesday, Wednesday

Weekend Requirements:




Position Status:


Number of Openings:


Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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