Director Quality

CommonSpirit Health•Carmichael, CA

10d

About The Position

This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and identifies opportunities for improved patient care, incorporate evidence-based practices, and improved patient outcomes. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement and Patient Safety plans and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and patient safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles. Oversees the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability). Participates in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care. Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing and focused practitioner evaluation. Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency.

Requirements

Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.
Minimum of five (5) years of progressive management responsibility in an acute care setting, two (2) of which is related to managing an organization’s Quality Improvement Program.
Minimum of two (2) years of clinical, patient care experience or equivalent.
Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.
Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN).
Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; Joint Commission, etc.).
Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.
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 is required
Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities
Experience with the event reporting process, root cause analyses, and event investigation/review
Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/reward contributions; define clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary
Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations
Ability to identify opportunities and take action to build strategic relationships between one’s area and other areas, teams, department, units or organizations to help achieve business goals.
Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization.

Responsibilities

Design, coordination, implementation and management of the Performance Improvement (PI) plan
Identifies opportunities for improved patient care, incorporate evidence-based practices, and improved patient outcomes
Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes
Establishes performance improvement goals annually with relevant stakeholders
Ensures the Performance Improvement and Patient Safety plans and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually
Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning
Assures data is managed appropriately and disseminated to appropriate leadership staff
Provides leadership in developing quality improvement and patient safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles
Oversees the events reporting process, root cause analyses, investigations and requests from the claims team
Participates in system office initiatives and programs to mitigate risks in the facility
Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes
Provides leadership and is responsible for accreditation and regulatory survey readiness
Oversees mock survey tracers to assess survey readiness
Provides education to staff and providers on regulatory compliance
Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency