ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE:                                      Safety & Quality Operations Coordinator

REPORTS TO POSITION:       Director, Quality Management

DEPARTMENT:                        Quality Management

DATE LAST REVIEWED:         October 2026

OUR VISION:                           Creating America’s healthiest community, together

OUR MISSION:                         In the spirit of love and compassion, better health, better care, better value

OUR VALUES:                          Accountability, Caring, Safety and Teamwork

DEPARTMENT SUMMARY: The Quality Management Department provides essential services to St. Charles Health System (SCHS) including:  Quality Improvement support, Accreditation and Licensing expertise, auditing support, Data Abstraction, Data Analysis, Document Library management and support, Environment of Care program management, Emergency/Safety program management, Infection Prevention program management, Caregiver Health program, Injury Prevention program, and Patient Experience program management.

POSITION OVERVIEW: The Safety & Quality Operations Coordinator (SQOC) provides centralized operational coordination for regulatory compliance, accreditation readiness, quality improvement, patient safety, risk management, and Environment of Care activities across St. Charles Health System. Supporting the Senior Director of Facilities, Security, and Environment; Directors of Quality Management and Risk Management & Patient Safety; and Executive Medical Director of Quality, this position coordinates time-sensitive deliverables, maintains evidence of compliance, and tracks required activities and corrective actions across departments and campuses.

The SQOC maintains systems for monitoring deadlines, documenting committee oversight, organizing survey evidence, and escalating outstanding actions to accountable leaders. This work supports timely fulfillment of applicable regulatory, accreditation, and organizational requirements while preserving clinical and technical leaders’ capacity for assessment, investigation, and improvement. The position also provides administrative and logistical support and does not directly supervise caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Maintains a centralized compliance calendar tracking applicable regulatory and accreditation deliverables, committee reporting cycles, program evaluations, policy reviews, and corrective-action deadlines, in collaboration with responsible program leaders.

Coordinates survey and inspection preparation, logistics, and follow-up, including document requests, evidence organization, meeting schedules, and tracking of outstanding deliverables.

Maintains corrective-action tracking systems identifying findings, accountable owners, completion dates, monitoring requirements, and supporting evidence; follows up on outstanding items and escalates overdue or incomplete actions.

Coordinates documentation for committees supporting required quality, safety, and compliance programs, including agendas, minutes, attendance, reports, decisions, and action-item follow-through.

Organizes and maintains retrievable evidence of compliance, including approved plans, program evaluations, audit summaries, education records, and corrective-action documentation, consistent with organizational document-control and retention requirements.

Tracks completion of scheduled audits and sustainment monitoring, compiles results supplied by program owners, and prepares status reports highlighting gaps requiring leadership attention.

Coordinates preparation and routing of regulatory and accreditation submissions for review and approval by designated leaders and subject-matter experts.

Supports preparation of leadership and governing body reports documenting program performance, identified risks, corrective actions, and follow-up.

Identifies breakdowns in administrative processes that may jeopardize required deadlines or documentation and implements improvements in collaboration with accountable leaders.

Maintains electronic schedules including coordinating internal and external departmental and project team meetings.

Connect records to committee oversight, decisions, and action completion.

Provides administrative support for medical staff quality and safety activities as directed by the Executive Medical Director of Quality.

Maintains department documentation to keep organized, current, retrievable evidence of compliance.

Maintains a repository of tools, templates, process improvement/Lean techniques for Quality & Safety -sponsored efforts.

Works with directors and managers to create and distribute daily, weekly, and monthly reports as requested.

Maintains the Quality & Safety internal site with relevant tools and templates.

Leads knowledge capture upon completion of projects (i.e. identifies learnings, builds/revises templates).

Supports the execution of a master communications calendar for all Quality & Safety-related communications.

Supports the development of Quality & Safety-specific learning and development efforts.

Consistently exhibits behavior and communication support skills that demonstrate commitment to superior customer service, including quality, care and concern with each internal and external customer.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. 

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:             

Required: Bachelor’s degree in healthcare administration, business or other related field. Equivalent professional work experience may be substituted for Bachelor’s degree.

Preferred: N/A

LICENSURE/CERTIFICATION/REGISTRATION:

Required: Valid Oregon driver’s license and ability to meet St. Charles Health System’s driving requirements. Ability to travel to all St. Charles Health System’s worksites and partner organizations across Oregon.

Preferred: N/A

EXPERIENCE:

Required: Minimum three (3) years’ experience in administration and support.

Preferred: Healthcare operations experience with proven ability to manage multiple projects, meet timelines and escalate effectively to meet project goals. Experience with varying exposure to strategy and project management.

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION:

Skills:

Excellent written/verbal communication and time management skills.

Excellent analytical and organizational skills, including the proven ability to adapt to a dynamic project environment and manage multiple projects.

Ability to communicate (verbally and written) effectively with clients, stakeholders, and senior leadership. 

Excellent time management skills. 

Ability to organize and work effectively with project teams of staff from department and clients participating in this effort. Demonstrated customer service excellence.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%):  Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%):  Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

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