Senior Director of Quality and Patient Safety

Job Summary

Under the general direction of the Vice President for Quality and Patient Safety, the Senior Director for Quality & Patient Safety, Saint Francis (SF) and St. Mary's (SM).
provides strategic direction, executive level leadership, planning, organization and general management for all aspects of the SF's and SM's Quality & Patient Safety program. This highly visible and matrixed senior leadership role will partner with the SF and SM executive team, the UCSF Health Quality and Patient Safety executive team and other key partners (e.g. physician leaders, UCSF Health leaders, affiliates/partners, etc.) to develop and execute a strategy for Quality and Patient Safety across the SF and SM enterprise. The incumbent is responsible for meeting or exceeding the institutional goals set for Quality & Patient Safety across SF and SM and to external reporting bodies.

Specific areas of responsibility include the following:

• SF and SM Quality Improvement (across spectrum of care at UCSF Health Community Hospitals)
• Patient Safety
• Regulatory Compliance, in partnership with UCSF Health Director of Regulatory Affairs
• Hospital Epidemiology & Infection Control (HEIC),
• Data Analytics
• Patient Experience, in partnership with UCSF Health Division Director of Experience
• Quality and Regulatory for 20 outpatient departments:
  • MACRA/MIPS quality measure & submission
  • CLIA licenses
  • SF city business licenses
• Outpatient Prospective Payment System (OPPS) management
• RAC audits (Reduction Recovery Audits)
• On-site Payor audits for clinics (i.e. BCBS)
• CMS STARs rating review & analysis, and action planning
• Accreditation programs/surveys not covered by Regulatory:
• CEEP School (Counseling Enriched Education Program)
  • San Francisco Department of Public Health Community Behavioral Health Services annual program audit
• College of American Pathologists/ Laboratory (CAP)
• Surgical Review Corporation for Transgender Program
• American Burn Association Burn Center Verification ICU Burn Unit
• San Francisco Department of Public: Business Office of Contract Compliance for Integrated HIV Services Review
• California Department of Public Health Infectious Disease Bureau
• Diabetes Self-Mgmt Training (DSMT) entity Audit (CMS via IMS)
• Commission on Accreditation of Rehabilitation Facilities (CARF)
• Inpatient Diabetic Nurse Educator (review hypoglycemia episodes, diabetic champions, etc)
• Orthopedic Service Line
  • IPPS
  • CMS Core Measures
• Leapfrog Survey

The final salary and offer components are subject to additional approvals based on UC policy.

Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.

The salary range for this position is $144,200 - $350,000 (Annual Rate).

To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html

Required Qualifications

• Bachelor's degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience
• Advanced degree in Nursing or related Health Care field (e.g., MPH, MBA, MHA, etc.) or an equivalent combination of education and experience
• At least 5 years of increasingly responsible management and leadership experience in a large academic medical center and/or a large medical center with a proven track record in quality improvement, program development, and related planning (ideally in a multi-site hospital system)
• Strong hospital management experience, with progressive and in-depth expertise in quality and process improvement methodologies, statistical analysis, and data base management
• Strong organizational and leadership skills to solve complex issues
• Must communicate with impact, to build and maintain a climate of trust
• Must interact and negotiate in a professional manner with a variety of highly influential entities, including the Chancellor and Campus Senior Leadership, UCSF Health and School of Medicine Leadership, major donors/members of the UCSF Foundation, Congressional and Legislative offices, UCOP, Deans, Department Chairs, Chiefs (e.g., CMO, CNO, CIO) and Faculty, and Department and Clinical Managers
• Advanced analytical, organizational, and problem-solving skills, with in-depth ability to develop and pursue goals, synthesize data to identify system vulnerabilities and develop and apply innovative solutions
• Astute in hospital finance and information systems; business acumen and analytic skills
• Excellent skills in developing strategic plans, creating benchmarks, integrating programs, building staff competencies, organizing operations, and fiscal management
• Excellent leadership and fiscal management skills, with the ability to create a goal-oriented climate of teamwork, collaboration, and consistent achievement of objectives
• Demonstrated leadership/management skills and excellent interpersonal relationship skills
• Proven track record in recruitment, retention and development of talent
• Strong ability to work collaboratively and effectively with medical staff, nursing leadership, ancillary departments, and staff
• Commitment to an academic mission which supports education, research, and staff development
• This position requires flexibility to orient and work at all UCSF Health locations as needed

Preferred Qualifications

• National specialty certification (e.g., CPHQ, CCDS, NEA-BC, CENP)
• Experience with LEAN methodologies and/or knowledge and support of LEAN principles
• Previous executive level experience
• Strong knowledge of relevant healthcare information technology, including QI workflows and processes, relevant systems and data management techniques and methodologies
• Strong knowledge of relevant QI regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments

Equal Employment Opportunity

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

Department Description

The Department of Quality & Safety consists of Adult Quality & Safety, Benioff Children's Hospitals (BCH) Quality & Safety, Saint Francis and St. Mary's Quality and Safety, Hospital Epidemiology & Infection Prevention, Regulatory Affairs, Health Equity, Clinical Documentation Integrity, and Risk. The teams are made of multidisciplinary professionals with diverse backgrounds. The role of the Department is the support UCSF Health to deliver safe, equitable and high-quality care to the communities we serve.

About UCSF

At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team.

Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents.

Pride Values

UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as our PRIDE values.

In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at diversity.ucsf.edu

Join us to find a rewarding career contributing to improving healthcare worldwide.

---