Director Quality

2 weeks ago

San Francisco, United States CommonSpirit Health Full time

Overview: St. Marys Medical Center has been caring for the health of San Franciscans since 1857 when it was founded by eight Sisters of Mercy from Ireland. It is an accredited not-for-profit hospital located across the street from Golden Gate Park. It is a full-service acute care facility with more than 575 physicians and 1100 employees who provide high-quality and affordable health care services to the Bay Area community.Home to advanced medical practices such as the nations first digital cardiac catheterization laboratory innovating orthopedic and spine surgery and comprehensive rehabilitation and a state-of-the-art cancer center. St. Marys Medical Center is one of San Franciscos leading hospitals offering patients a full range of outpatient and inpatient services delivered with the human touch. Strategies and business development are centered on Oncology Services Cardiac Services and Orthopedics.

Responsibilities: 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 organizations 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.

Qualifications: Education and Experience: Bachelors 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 organizations 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.). Licensure: 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.

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