Director of Quality

3 weeks ago

Fresno, United States The Physicians' Group Full time $63 - $87

Fresno Surgical Hospital is known for excellence in surgical care delivery and patient satisfaction. Our goal is to provide a high quality of care through compassion to all we serve by creating a supportive environment for patients, clinical staff and employees.

The Director of Quality Management and Risk provides strategic and operational leadership to the performance measurement/reporting/improvement and Risk Management/Regulatory Compliance functions.


Required Skills

Minimum Education & Experience

  • Graduate from an accredited school of Nursing.
  • Additional course work in performance improvement and CQI desirable.
  • Minimum of 5 years management experience of an acute care hospital for operational efficiency, strategic and financial planning, team building, quality/risk management and regulatory compliance or equivalent combination of education and experience.

Required License/Certification

  • Current RN Licensure in the State of California
  • BLS certification
  • CPHQ certification preferred.

Required Skills

  • Familiar with all related healthcare concepts, practices, policies and procedures.
  • Knowledgeable of Joint Commission, HIPAA, AAHC and other healthcare governing bodies, both state and federal.
  • Ability to understand basic quantitative concepts, analyze complex tasks, systems, problems and determine solutions.
  • Ability to communicate effectively in English, both verbally and in writing.
  • Ability to be flexible, organized, and function under stressful situations.
  • Ability to maintain collaborative working relationships to ensure a positive and productive work environment.
  • Ability to provide exceptional customer service.
  • Able to communicate professionally at all levels within and outside of the organization.
  • Able to effectively plan and prioritize work while dealing professionally and effectively with frequent interruption.
  • PC competency, working knowledge of Microsoft Office Products (Word/Excel).

Essential Functions

  • Responsible for planning and implementing the quality assurance performance improvement program to meet the needs of the hospital. Oversight of quality assurance performance improvement and CQI activities throughout the hospital.
  • Oversees infection surveillance, infection control rounds and monthly hand hygiene audits.
  • Oversight of Quality, Medical Staff Peer Review, Risk Management, Infection Prevention, and Medical Staff Office to ensure optimal performance and to provide direction/guidance on flow and departmental issues.
  • Demonstrates effective organizational skills through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team and Governing Body to facilitate an effective hospital-wide QAPI program.
  • Chairs Hospital Wide Quality Committee and attends Medical Staff Peer Review meetings, Infection Prevention meetings, Medical Staff and Leadership meetings.
  • Responsible for the hospital’s Emergency Disaster Preparedness in conducting disaster drills, as required by Joint Commission.
  • Provide leadership in the design and implementation of leading edge strategies that align FSH measurements and improvement initiatives with emerging national and state requirements.
  • Serves, in conjunction with the FSH infection prevention nurse, to ensure that all quality and benchmarking surveys are kept current and the data is submitted on time.
  • Responsible for clinical identification, risk evaluation and coordination of corrective action implementation related to risk issues.
  • Coordinates risk programs with all hospital departments, and administration.
  • Serves as the Risk Manager for FSH and is accountable for managing and coordination activities of risk management.
  • Serves as the Patient Safety Officer and is the Chair of the Patient Safety Committee.
  • Utilizes systems for risk identification, investigation, and reduction.
  • Collects, evaluates, follow-up on all occurrence reports; distributes relevant data regarding incidents/injuries.
  • Works in collaboration with Medical Staff and CNO to follow-up on patient complaints/grievances.
  • Facilitates/assists with general and professional liability claims; interfacing with defense legal counsel.
  • Works in collaboration with hospital management and Facilities manager as the Safety Officer.
  • Incorporates OSHA standards into the work environment.
  • In conjunction with the CNO responsible for all regulatory and accreditation involving the Joint Commission and the CDPH.
  • Demonstrates knowledge of current methodology and practices.

Fresno Surgical Hospital complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce.

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