Director of Quality

Job-8308

Quality Assurance-Director of Quality

King City, CA

Seeking a Director of Quality to work collaboratively with Hospital Executive Team, leaders, physicians, and staff to reduce patient, guest, and employee risk and to promote quality patient care and safety.

This is accomplished through various assessment activities, process improvement activities and through committees or meetings including Quality, Patient Safety, Corporate Compliance, Complaints and Code Blue.

Directs and leads all compliance, quality and risk management activities for the hospital including patient care and relations, and accreditation / licensing survey readiness.

Develops strategic plans and policies for improved quality throughout the system and works with leaders to ensure compliance with regulatory agencies.

Manages and coordinates efforts to ensure that quality management programs are developed and managed using a data driven focus and sets priorities for improvements aligned to ongoing strategic imperatives.

Duties include oversight of Risk Management and Compliance.

Essential Function

1. On-going assessments of regulatory related, performance improvement and risk management compliance policies and procedures and assist in updating or developing new policies to enhance this position’ areas of operations.

2. Carry out a vulnerability analysis on the organization’s quality programs and activities, discover areas of potential risk and vulnerability, and create and implement solutions to quality measures compliance.

3. Manage and direct healthcare training and educational programs to advance awareness, education, and readiness for Joint Commission and other related agency-audit visits.

4. Conduct or delegate investigations and coordinate internal and external corrective measures to be executed relative to identified deficiencies noted in quality adherence.

5. Establishes and maintains a mechanism to track quality related information and review or receive a report on the findings of such activities.

6. Stay informed of current quality issues affecting the healthcare industry, as well as quality program best practices.

7. Prepare report for management on incidents arising out of deficiencies related to quality, investigations, and all significant quality deficiencies with recommendation(s) to resolve.

8. Carry out due diligence on new healthcare businesses / services before they are implemented and design effective quality assurance plans.

9. Accurately, timely, and with due diligence will assist in the preparation and presentations for Joint Commission and other related surveys reflecting compliance to clinical and non-clinical integration of standards.

Identifies deficiencies and assists in remedial resolution of such.

10. Champions clinical quality performance and patient safety, to meet established patient safety, quality, and compliance goals across multiple communities.

11. Directs the development of programs and processes related to Performance Improvement across multiple employee populations based on the unique volume and services at each site.

12. Provides education to all quality leadership and executives.

13. Facilitates organization wide transition to a High Reliability Organization through development of policies, standards, indicators, implementation, and evaluation techniques.

14. Develops policies and procedures, monitors performance, develops and reviews metrics, assesses and prioritizes risk, and reports results to leadership.

Serves as a resource to quality teams, medical staff, and executives.

15. Develops and maintains quality and patient safety plans that align with the organization and are relevant to the unique volumes and services at each site.

16. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives.

17. Supports sites in scope in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees.

18. Facilitates development of proactive programs that use standardized Performance Improvement (PI) and Root Cause Analysis (RCA) techniques to minimize risk.

19. Proactive evaluation of safety and near miss events, cost, place, treatment, for the purpose of making recommendations for improvement using standardized Performance Improvement (Pl) and Root Cause Analysis (RCA) techniques.

Supervises accreditation program and ensures ongoing preparedness for meeting requirements for regulatory and licensure.

20. Oversees the Infection Prevention program for the organization.

21. All other duties as assigned.

QUALIFICATIONS

Education :

• Bachelor’s Degree in a healthcare related field
• Master’s degree in healthcare or an organizational leadership field Preferred

Work Experience :

Minimum three years, recent full-time experience in managing a healthcare facility’s Performance Improvement, risk, and compliance activities

Licensing Requirements :

• Current State License in a clinical field
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment.

Obtained within one (1) year of hire

Full time position, Salary negotiable based on experience plus benefits.

Located in Monterey County, CA. on the Salinas River of California's Central Coast. A population 13,332 at the 2020 census.