Director Quality
2 weeks ago
[
**Hours**:
**Shift Start Time**:
9 AM
**Shift End Time**:
5 PM
**AWS Hours Requirement**:
8/40 - 8 Hour Shift
**Additional Shift Information**:
**Weekend Requirements**:
As Needed
**On-Call Required**:
No
**Hourly Pay Range (Minimum - Midpoint - Maximum)**:
$75.051 - $96.840 - $118.629
**What You Will Do**
The Director of Quality and Patient Safety is responsible for providing the oversight, direction, coordination and integration of quality and patient safety; for contributing to the strategic planning for the hospital to achieve the SHC vision; for executing entity strategic plans, and for partnering with executives, directors and department leaders in continuously improving clinical outcomes and reducing risk.
The position is also responsible for the effectiveness and efficiency of adverse event reporting and risk reduction, physician peer review, clinical analytics, data management and report distribution.
**Required Qualifications**
- 5 years of leadership experience.
- Clinical background, such as RN, PharmD.
**Preferred Qualifications**
- 5 years of performance improvement experience.
**Other Qualification Requirements**
- Graduate degree is required upon hire or completed within six months of hire date.
- CPHQ, CPPS, ASHRM certification preferred.
**Essential Functions**
- ** Strategy Planning for Quality, Patient Safety and Performance Improvement**
Leads the entity’s Quality Assessment and Performance Improvement (QAPI) program and patient safety culture in part by positioning the Quality Department to be a critical and central element to strategic planning and program development under the Quality Pillar
In collaboration with Clinical Effectiveness, entity executive teams and other entity leaders, conducts strategic planning and sets short
- and long-term goals for quality, patient safety, and performance improvement.
In collaboration with entity leaders, creates and improves systems and structures to support the achievement of quality and patient safety goals.
- ** Strategy Deployment for Quality, Patient Safety and Performance Improvement**
Serves as the Patient Safety Officer.
- Ensures adequate resource allocation and manages the dedicated patient safety program budgets to support the program and staffing. Recommends technology investment related to patient safety.
- Recommends financial incentives for leadership related to the patient safety strategic plan.
- Directly accountable for improvements in patient safety performance.
- Evaluates current safety practices and identifies gaps in comparison to the National Quality Forum (NQF) practices as published in their Safe Practices for Better Healthcare: A Consensus Report. Considers other sources for patient safety best practices. Prioritizes the patient safety work plan accordingly.
- Provides reports to governance on safe practices and the patient safety strategic plan.
- Collaborates with senior leadership and clinical effectiveness to oversee culture of safety assessments and response to results.
- Informs executive committee, mid-level management and physician leadership about the need for teamwork training, skill building, and identified internal and external resources.
Partners with and supports the following entity executives, directors, and department leaders to identify improvement opportunities; select appropriate methodology; assemble and manage required resources; adopt, develop and modify key performance metrics; evaluate the effectiveness of quality, patient safety and performance improvement strategies and tactics and to coach/advise on course corrections where needed:
- Entity executive team
- CMO, Medical Staff and Medical Executive Committee
- Medical Staff Office
- Center of Nursing Excellence (CONE) and the CNS/Specialists
- System Quality and Patient Safety Director
- System Lean Six Sigma Director
- Infection Prevention
- Pharmacy
- Information Systems
- Home Health
- Case Management
- Service Lines - Ortho/Neuro, Cardiac, Diabetes, Oncology, Surgery, Women’s
- Hospice (SGH only)
- Regulatory
- Legal
- Finance
- HIM and Coding
- Community Care Transitions Program
Monitors all publicly reported quality results, ensures accuracy of data, and communicates results to all stakeholders. Collaborates with senior leadership to prioritize and close gaps in external ratings.
Coordinates the dissemination of accurate, timely, accessible, and actionable quality and patient safety reports to help leaders and staff identify and address opportunities to improve clinical processes and outcomes.
Partners with and executes plans for external agencies and Collaboratives (such as Patient Safety First (PSF), California Maternal Quality Care Collaborative (CMQCC)
Collaborates with Regulatory Director on organizational regulatory preparedness and compliance with local, state and federal laws.
Assures that improvement activities are documented and reported within the organization and externally as appropriate.
- ** Leadership
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