Job opening for a Quality Management Director located in Southern California.
With the recent addition of the Rehabilitation Institute, the hospital features 184 licensed acute care beds as well as inpatient and outpatient surgery, cardiac services featuring a STEMI Receiving Center (heart attack) and a 35-bed 24-hour emergency department. The Center for Wound Care provides treatment for people with chronic non-healing wounds. This comprehensive wound-healing service includes hyperbaric oxygen therapy. The Medical Center is active in the community and regularly participates with the Antelope Valley Board of Trade, Greater Antelope Valley Economic Alliance, Chambers of Commerce and other civic and governmental groups. The Medical Center believes in “Community Service Excellence” and supports nonprofit agencies such as the American Cancer Society, United Way, the Antelope Valley Boys and Girls Club and performing arts organizations. Building a Healthier Community…Big Changes are already here!
The Director of Quality Management oversees and mentors staff in the collection, analysis, and reporting of data, facilitating improvement projects, assessing for and implementing risk reduction measures and assessing and coordinating activities related to achieving and maintaining ongoing regulatory compliance. Acts as the organizational point-person for interactions with regulatory agencies and provides facility-wide support for improving work processes, patient outcomes, risk reduction and acts as an educational reference.
- Minimum five (5) years-experience in acute care quality management, with at least years in a supervisory role. Experience in peer review required. Certified Professional in Healthcare Quality (CPHQ) desired.
- Graduate of an accredited School of Nursing or Equivalent. Bachelor’s degree required.
- License, Certification, or Registration required: For RN candidates: Current, active Registered Nurse licensure in the State of California. For non-RN candidates: Appropriate current, active clinical registration/certification. Current Basic Cardiac Life Support certification.
POSITION SPECIFIC RESPONSIBILITIES:
- Oversees the effective development, implementation, and evaluation of the Quality Management Program.
- Assesses for compliance of regulatory requirements, disseminates information on new regulatory requirements, coordinates making changes to policy/practice related to meeting requirements, including contract review, coordinates accreditation activities and inspections and acts as org contact with regulatory agencies.
- Assists various services in developing criteria for monitoring performance and following up on findings implementing corrective action plans while providing data-driven information hospital wide.
- Oversees the medical staff peer review process, reappointment clinical profile reporting, and addressment of disruptive physicians by working closely with the medical staff leadership.
- Promotes a culture of safety, proactive prevention of risks and infections, and philosophy of continuous improvement.
- Coordinates the review and investigation of risk claims cases, depositions, gathering of information and keeping senior leaders apprised of such cases through appropriate reporting to senior leadership, medical staff leadership, and corporate leadership as it relates to performance improvement, risk management and infection prevention.
- Coordination and linkage of Performance Improvement, Clinical Quality and Service Excellence, Risk Management, Infection Prevention and Regulatory requirements. This includes the execution of shared processes of MIDAS (Event) reports, ENS (Initial and Follow up) Root Cause Analysis, Failure Mode and Effects Analysis (FMEA), AHRQ Culture of Safety Survey, Patient Safety Council, Patient Safety Alerts, oversight of PSES Member site and Member Workforce Education & Confidentiality Agreements, and needed.
- Clarifies outcomes from survey data or PI reviews with various services when findings are unclear or noncompliant.
- Maintains current competency related to Performance Improvement, Risk Management, Patient Safety, and Joint Commission, DHS, local agency C MS Regulations.
- Participates and/or leads team activities toward achieving improvements in performance hospital-wide.
- Networks with other professionals in the field.
- Maintains confidentiality of information.
- Establishes and maintains effective working relationships with customers, i.e. peers, staff, medical staff, and public agencies, etc.
- Promotes a culture of safety, proactive prevention of risks and infections, and patient-centered care philosophy of continuous improvement.
- Provides staff education and acts as a facility resource.
- Reports to COO
- FTE’s: 3
Competitive Salary Range!
Executive & Management Recruitment Services
(415) 770-1200 – call/text-the quickest way to reach me.