Quality Director

Mountains Community Hospital•Lake Arrowhead, CA

About The Position

The Quality and Regulatory Compliance Director is responsible for the program development, implementation, and management of Quality improvement initiatives, risk management, corporate compliance, patient safety and patient experience activities throughout the hospital district. This Director effectively engages everyone in the organization to improve quality performance and communicates all quality activities to the medical staff, Board of Directors, administration and staff. This position is responsible for gathering and reporting quality data to outside quality improvement organizations in an accurate and timely manner. This Director coordinates, investigates, and responds to customer complaints and patient-related issues. This Director is also responsible for maintaining regulatory compliance of the organization and has a working knowledge of State and Federal regulations.

Requirements

Bachelors’ degree required
Experience required
Current RN License in California or ability to obtain CA license within 30 days of hiring is required

Nice To Haves

CPHQ certification preferred

Responsibilities

Preparation for and coordination of regulatory surveys
Regulatory survey response and compliance
Regulatory Self-reporting activities and follow-up
Quality Review Report review and follow-up
Failure Mode and Effect Analysis and Root Cause Analysis investigation and reports
Complaints: investigation and follow-up
Patient satisfaction surveys
Beta HEART program
Service Excellence Initiative oversight
Committees
Continuous Quality Improvement Program
Nurse Advisory and Regulatory Compliance Committee
Board of Directors Quality Committee
Peer Review chart prep and committee participation
Medication Error Reduction Program
Falls Committee
Wound Care Committee
Fire, Life, Safety/Emergency Operations Committee
Team Walk Rounds
Beta HEART Steering Committee
Service Excellence Council
CHA Certification and Licensing Committee
Medical Executive Committee
Infection Control Committee
Medi-Tech Clinical Systems Optimization Committee
Patient & Family Advisory Council
Corporate Compliance Committee
Data Collection and Reporting
Emergency Department Transfer Communication
Departmental Quality Dashboards
Patient Experience Surveys
MBQIP, NHSN, HQR (IQR, OQR), eCQMs, TJC DDSP Dexur – IQR, OQR, SIERA files HQIP – IQR, OQR Survey Solutions
Ongoing Professional Practice Evaluation
Department Manager meeting
New Employee Orientation – Quality, Service Excellence
Policy review and development
FLEX and SHIP Grant management