Description

Provides leadership in the promotion of a culture of safety, and the measurement of the quality-of-care identifying opportunities, and strategies for performance improvement (PI). Directs and coordinates licensing, accreditation, policy, and regulatory affairs initiatives, and assures compliance. Provides oversight and direction for risk management, infection prevention, patient safety, high reliability, medical staff peer review, physician quality reporting, patient satisfaction, performance improvement, data management, and the grievance/complaint process. Serves as the Discrimination Officer.

Requirements

Essential Duties and Responsibilities

• Initiates and oversees a comprehensive patient safety/quality/performance improvement program inclusive of the analysis and trending of data related to initiatives.
• Responsible for and ensures annual review, and approval, of the QA/PI Plan, Risk Patient Safety Plan; and the Infection Control Plan, developing hospital-wide compliance, assuring follow-up and responses in a timely manner.
• Serves as the Discrimination Officer following the Equal Opportunity Act and the Patient Bill of Rights and Responsibilities by ensuring equal access to healthcare, prohibiting discrimination, and requiring equitable treatment for all patients, regardless of their background.
• In conjunction with the Medical Staff, and system leadership, directs and coordinates quality/performance improvement/risk/patient safety/high reliability/infection prevention/patient experience/quality data management initiatives.
• Provides oversight of patient safety activities, including root cause analysis/event analysis/case reviews, in regard to the facilitation of process, planning, implementation, communication, and evaluation of effectiveness of process changes.
• Prepares reports to Board of Directors and Medical Staff Quality Committee regarding Risk/Patient Safety, Service Excellence, and Quality/Performance Improvement Program.
• Coordinates the Board Quality Committee and Medical Staff Quality Committee quarterly meeting agenda and attachments.
• Regularly communicates PI and quality/patient safety activities to leadership and staff.
• Promotes interdepartmental, and Medical Staff collaboration, to develop a cooperative effort in the endorsement of a patient safety, risk mitigation, and quality management focused program utilizing high reliability principles.
• Implements organizational-wide programs, policies, and procedures to ensure the District's compliance with applicable federal and state laws and regulations, such as those for CMS, ACHC, CDPH, HCQC, and other regulatory agencies.
• Maintains awareness of healthcare laws and regulations, keeping abreast of current changes that may affect the organization. Shares with applicable
• Director/Managers and Medical Staff, and monitors compliance.
• Oversight for the development and monitoring of unit/department specific QA/PI plans, initiating appropriate action to improve outcomes.
• Responsible for the Grievance/Complaint program related to quality-of-care concerns, ensuring hospital-wide compliance with follow-up, and timely patient responses.
• Integrates High Reliability organizational principles, in every aspect of Quality & Regulations, to mitigate risks.
• Collaborates with Directors/Managers, and Medical Staff, regarding patient satisfaction results, and develops plans for improvement.
• Establishes mechanisms to assess and document regulatory compliance and serves as the primary liaison with regulatory agency officials.
• Serves as the primary contact with regulatory agencies related to surveys and licenses.
• Responsible for the following contracts: Beta Healthcare Group; Alliant Insurance; RL Datix; Press Ganey; QCentrix; ASM MD Stat; Health Services Advisory Group (HSAG); Quality Improvement Organization (QIO) related contracts; Collaborative Healthcare Patient Safety Organization (CHPSO), Sierra Collaborative external peer review, and other Quality related contracts.
• Demonstrates a passionate commitment to open communication and leadership following communication principles and System values. Committees / Meetings Required to Attend
  • Board of Directors – monthly
  • Board of Directors Quality Committee – quarterly
  • Medical Executive Committee – monthly
  • Medical Staff Quality Committee – quarterly
  • Medical Staff Department and Committee meetings – quarterly
  • Cancer Committee – quarterly
  • Performance Improvement Committee – monthly
  • Director/Manager meeting – monthly
  • Environment of Care – bimonthly
  • Reliability Management Team – ad hoc
  • Safety Huddles – daily during the week
  • Patient & Family Advisory Council -- monthly

• Demonstrates leadership and professional growth
• Develops budgets and capital equipment needs for areas of responsibility
• Demonstrates System Values in performance and behavior
• Complies with System policies and procedures
• Other duties as may be assigned

Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Supervisory Responsibilities
Carries out supervisory responsibility in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, training, assigning, coaching, counseling, and disciplining employees; administering scheduling systems; communicating job expectations; planning, monitoring, appraising, and reviewing job contributions; enforcing policies and procedures.

Minimum Education/Experience
Bachelor's Degree from four year college or university and 5 or more years relevant experience

Required Licenses/Certifications
Valid Driver's License in good standing - Upon hire

Other Experience/Qualifications
Required:

• Proven ability to develop and implement programs.
• Minimum two years in a decision-making management position.

Preferred:

• Master's Degree of Science (M.S)
• Certified Professional in Healthcare Quality (CPHQ)
• Certified Professional in Patient Safety (CPPS);
• Certified Professional in Healthcare Risk Management (CPHRM)
• Lean Certification