Administrative Director, Quality Management

1 day ago

san luis obispo, United States Adventist Health Full time

Sierra Vista


Nestled on the Central California Coast, Adventist Health Sierra Vista has been providing care to our community since 1959. Our 162-bed acute care facility includes a Level III Neonatal Intensive Care Unit and county designated trauma center. San Luis Obispo offers the excitement of a lively community while being a fifteen-minute drive from the serenity of Avila Beach, known for their natural hot springs, and Pismo Beach, known for their sand dunes and eucalyptus trees. Featuring a charming downtown, comfortable coastal weather, idyllic views, and an active lifestyle San Luis Obispo offers much to be had.


POSITION SUMMARY:

Maintains responsibility for Quality Management initiatives. Provides overall direction, development, implementation and integration of the Quality Management program which includes compliance with all the Joint Commission, Federal, State and local reporting requirements. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment. Leads, develops and deploys a comprehensive, highly reliable program across the continuum of care and implements the organization's vision of excellence in clinical and quality outcomes and patient safety. Establishes a system structure that supports the organization through analytics, analysis and High Reliability Organization (HRO) safety initiatives such as Culture of Safety, Just Culture and others included in strategic directives. Works closely with the ministry leaders of quality, physician services, nursing leadership and homecare to champion communication, transparency, teamwork and a culture of safety.


JOB REQUIREMENTS:

Participates in surveys of market best practices to identify loss control issues and opportunities for improvement.

Develops and maintains the quality plan and patient safety for the organization. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives. Directs efforts to ensure quality, patient safety and performance improvement implementation across the system. Supports organization in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees.

Collaborates with analytics teams to develop and maintain quality metrics services for our sites that meets required reporting such as Electronic Clinical Quality Measures (eCQM) and more. Works with analytic team and our Electronic Health Record (EHR) vendor to apply meaningful analysis and process improvement. Knowledge leader for Value-Based Purchasing (VBP), Healthcare Associated Infection (HAI), readmissions, mortality and more for any clinical performance programs such as government or commercial pay for performance. Supports quality metrics for contracted services as needed.

Evaluates various attributes of health care, such as safety, cost, place, accessibility, treatment, and benefits as compared with standard results, for the purpose of making recommendations for improvement using standardized Performance Improvement (PI) and Root Cause Analysis (RCA) techniques.

Performs other job-related duties as assigned


Education and Work Experience:

  • Bachelor's Degree or equivalent combination of education/related experience: Required
  • Master's Degree: Preferred
  • Ten years' technical experience: Preferred
  • Five years' leadership experience: Preferred
  • Ten years' healthcare system level quality leadership; Project management/lean or sigma training; Experience building or leading a High Reliability Organization (HRO): Preferred


Licenses and Certifications:

  • Registered Nurse (RN) licensure in the state of practice: Preferred
  • Certified Professional in Healthcare Quality (CPHQ) and/or Patient Safety Certification: Preferred


ORGANIZATIONAL REQUIREMENTS:

Adheres to the Adventist Health Mission, Vision and Values statements. Complies with behavioral standards, policies, procedures and handbooks established by the organization and their respective ministries. Abides by the guiding principles of the Code of Conduct.

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.

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