group
Category
Management & Supervision
business
Department
Quality Improvement
date_range
Schedule
Full Time
schedule
Shift
Day
timer
Hours
8 Hour Shift
place
Location
Rancho Mirage, CA 92270
info
Job #
R0252714

  • Job Description: A brief statement of the position, including the general job duties.
    • Provides leadership in the development of a culture of safety and the measurement of the quality of care identifying opportunities and strategies for performance improvement. Directs and coordinate Quality Improvement Program for the health system, including continuous process improvement, patient relations, accreditations, regulatory compliance, patient safety, infection control, and support for medical staff peer review. Develops strategic plans for improved quality. Works with senior management to ensure survey readiness. Has primary oversight of the health systems inpatient safety program. Directs others within the health system toward process improvements that will support the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes. Provides leadership for safety assessments & rounds, coordinates the activities of the patient safety team, educates other practitioners on the systems-based causes for medical error, consults with management and staff, and communicates evidence based recommendations regarding effective patient safety strategies to others within the organization. Acts as a health system-wide expert and resource in quality improvement.
  • Reports to
    • VP, Quality and Resource Management
  • Supervises
    • Infection Preventionists, Quality Analysts, Quality Program Managers
  • Ages of Patients
    • None
  • Blood Borne Pathogens
    • Minimal/ No Potential
  • Qualifications
    • Education
      • Required: Masters Degree in Nursing or other healthcare related field.
    • Licensure/Certification
      • For Registered Nurses – Required: California RN License, Certified Professional in Healthcare Quality (CPHQ)
      • For Pharmacists – Preferred: California License, Lean Six Sigma or other PI model certification.
    • Experience
      • Required: Minimum five years working in healthcare Quality Improvement or related field.
  • Specific Skills, Knowledge, Abilities Required
    • Computer skills, to include data entry, spreadsheets, graphics, information systems. Ability to collect, analyze and disseminate data, including financial and statistical data.
    • Knowledge of performance improvement tools, and the ability to use them effectively.
    • Excellent verbal and written communication and interpersonal skills; experience presenting data and information to physicians and other clinical staff as directed.
    • Experience working with clinical outcomes data systems and resource management.
    • Ability to set goals and work independently and efficiently with minimal supervision; ability to prioritize fluctuating workload and times to meet position demands.
    • Ability to work in a fast-paced environment and manage multiple meetings and projects.
    • Knowledge of regulatory standards including Joint Commission, Medicare (CMS) and Title 22 (state) requirements.
    • Data collection and analysis.
  • Essential Job Specific Responsibilities
    • Initiates and oversees the development of a comprehensive safety / quality / performance improvement program working in collaboration with nursing and medical staff leadership. This is inclusive of the analysis and trending of data related to initiatives.
    • Provides strategic oversight of proactive and reactive patient safety activities including RCA, FMEA and Sentinel Event Alerts in regards to facilitation of process planning. Implementation and evaluation of effectiveness of process changes.
    • Develops and implements the Strategic Plans for Quality and Patient Safety annually.
    • Supports the medical staff peer review process, OPPE and credentialing.
    • Responsible for accreditation and licensing survey readiness. Provides education to Administration Leadership and staff on regulatory compliance directly or through staff members.
    • Oversees mock survey tracers of the organization to assess survey readiness (also for all licensing inspections of new services).
    • Prepares action plans / responses to accrediting / regulatory surveys.
    • Oversees collection, submission of data reported internally and to external agencies (required or optional). Reports to appropriate organization entities.
    • Responsible for all licensing functions, applications for additional services, change in beds, services, etc.
    • Coordinates the Quality/Patient Safety Council, in collaboration with the Council Chairperson. Communicates pertinent reports to the medical staff and organization leaders.
    • Works closely with the Medical Staff Quality Analysts to ensure that agendas and reports for the medical staff QA&I and Committee meetings are complete and prepared in a timely manner.
    • Leads and supports performance improvement teams using lean concepts.
    • Recommends and facilitates change within the organization to improve patient safety, based on identified risks. Utilizes the hospital’s performance improvement model, to coordinate the redesign of the process and/or underlying systems to minimize the risk of that undesirable variation or to protect patients from the effects of that undesirable variation. Follows critical analysis and identification of failure mode (process variation) methodology.
    • Supports and encourages error reporting throughout the organization through a non-punitive error reporting systems.
    • Measures and evaluates effectiveness of quality and patient safety programs using established goals and prepares an annual report for the Governing Board.

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