Directs the Medical Center quality program for hospital & ambulatory sites, which may include one or more of the following: quality assessment & improvement, accreditation & regulation licensing, & compliance. Partners w/ the medical center executive leadership team & departments to ensure that the program effectively measures, assesses & continuously improves the quality of care & service provided. Manages the medical staff office functions for credentialing & privileging, CME, GME, medical library, & peer review. Partners w/ medical group to improve clinical performance & the medical center for operational performance improvement. Works in partnership w/ the AR&L director to lead regulatory compliance & to maintain accreditation status.
Essential Functions:
- Directs the medical center's quality mgmt program, which supports the organizational goals & priorities, as well as, the requirements of regulatory & accrediting agencies
- Provides oversight for the medical center wide involvement in quality improvements, communicate opportunities, results & priorities
- Works closely w/ designated Chiefs of Service & Dept Mgrs to address patient care issues w/ a goal toward resolution while maintaining confidentiality
- Provides education & technical support to the Medical Center in developing, implementing & maintaining quality improvement activities
- Identifies & implements practices to improve quality & service
- Collaborates w/ leadership, depts, clients, TPMG, & community in designing processes, tools & templates that continually improve the quality, efficiency, service & effectiveness of care & service
- Consults & participates in performance improvement teams using a variety of methodologies
- Partners w/ Risk Mgmt to reduce medical/legal liability through development of a program which links risk mgmt activities w/ those of continuous quality improvement
- Serves as a critical link in the identification & resolution of issues, which affect the organizational image
- Develops & maintains relationships & effective communication w/ all levels of medical center physicians & staff in order to facilitate problem identification & resolution
- Oversees preparation of periodic reports to the KFH/HP Board of Directors & coordinates completion of the Quality annual evaluation, workplan & program description
- Supports the peer review process & partners w/ medical staff to assure process completion
- Oversees Medical Staff Svcs including credentialing, privileging, CME/GME & library responsibilities
- Consults on data analysis techniques & evaluates trends to identify potential opportunities for improvement
- Manages staff & makes recommendations regarding the need for staff, space & other resources
- Manages & resolves HR & labor relations issues specific to mgmt responsibilities
- Develops systems, templates, tools & processes to identify & monitor indicators which best measure improvement in care delivery
- Partners w/ AR&L Director to prepares for surveys & inspections, including educational forums, coordinating mock surveys & assessments assists in developing response plans
- Interprets & assists in planning responses to new or changing regulations or standards
- Collaborates w/ external regulators to develop standards, which promote high quality patient care & svcs
- Develops, implements, & meets the established financial goals
- Monitors applicable budget, & identifies & supports solutions to reduce cost structure
- Perform other duties as assigned
Qualifications:
Basic Qualifications:
- Experience designing, developing, implementing clinical improvement programs
- Significant experience, usually five (5) years, in Quality Improvement in a health care setting
- Previous management experience required
- Previous management experience in nursing or other allied health professional experience preferred
- Bachelor's degree in health care administration, nursing, or public administration or related field required
- Master's degree preferred
- Current California RN license (preferred) or other clinical licensure required
- Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred
- Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement, such as The Joint Commission, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22, Cal-OSHA, HIPAA and Medi-Cal and Medicare regulations and standards
- Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques
- Effective communication, negotiation and leadership skills
- Must be able to work in a Labor/Management Partnership environment
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.