Director of Quality, Safety, and Clinical Effectiveness

AVALON MEDICAL DEVELOPMENT CORPORATION•Avalon, CA

About The Position

Catalina Island Health is seeking a strategic and hands-on Director of Quality, Safety, & Clinical Effectiveness to lead and strengthen our Quality Assurance and Performance Improvement (QAPI), patient safety, infection prevention, regulatory readiness, and clinical effectiveness programs. This leadership role is responsible for ensuring compliance with CMS Critical Access Hospital (CAH) Conditions of Participation, California Title 22 regulations, and applicable regulatory and accreditation requirements. The Director partners with clinical and operational leaders across the Emergency Department, Acute Care, Swing Bed, Skill Nursing, and ancillary services to drive continuous improvement, enhance patient outcomes, and support a culture of safety and accountability. This position reports to executive leadership and plays a critical role in organizational readiness for CMS and CDPH surveys.

Requirements

Strong knowledge of CMS CAH Conditions of Participation and regulatory requirements.
Experience with QAPI programs, performance improvement methodologies, and root cause analysis.
Strong leadership, organizational, and analytical skills.
Ability to collaborate effectively across all levels of the organization.
Excellent written and verbal communication skills.
Ability to manage multiple priorities in a dynamic healthcare environment.
Strong facilitation, coaching, and communication skills, systems thinking and analytical problem solving.
Bachelor's degree in Nursing or a related health field required.
3-5 years of hospital quality, patient safety, or PI experience.
Possess license as a Registered Nurse in the State of California.
BLS/CPR certified.

Nice To Haves

Master's degree in Nursing, Healthcare Administration, Public Health, or related field preferred.
CPHQ, CPPS, or CIC certification.

Responsibilities

Serve as the organization-wide leader for the CAH's QAPI program. Develop and implement the annual QAPI Plan for the organization.
Responsible for maintaining and keeping current three copies of the Quality Program, Infection Control and Prevention Manual. This includes oversight of and supporting the review, updating and development of Infection Control/Infection Prevention (IC/IP).
Facilitates, supervises and/or performs the duties and responsibilities as outlined int eh Quality Improvement Plan. Review plans for effectiveness on an annual basis.
Facilitate QAPI meetings.
Orient new front-line staff and leaders to Quality expectations as applicable to role in organization.
Performs function as liaison to the Quality Improvement Organization and California Department of Public Health for Infection Prevention and Quality monitoring.
Facilitate or conduct routine organizational-wide infection control surveillance and safety inspections. Document findings and notify the department managers and appropriate staff as indicated.
Supervise or facilitate health information reporting requirements related to applicable legal, licensing, and accreditation requirements as well as administrative reports.
Gather information needed to fulfill specific health information reporting requirements related to applicable legal, licensing, and accreditation requirements as well as monthly and quarterly administrative reports where applicable.
Provide or facilitate annual education and competency requirements per Title 22, CDPH, and CMS and whenever a need is recognized or required for all staff.
Facilitate and lead PDSA cycles, root-cause analysis, and corrective action development.
Oversight of the Patient Safety Program and internal reporting systems.
Conduct organization-wide risk assessments and safety rounds.
Ensure Infection Prevention & Control Program integration into QAPI and ensure compliance with evidence-based IC practices and outbreak investigations.
Partner with IP Lead, Laboratory and Pharmacy to support Antibiotic Stewardship.