Director, Quality & Patient Safety (Acute RN)

Organization:

MHLB-Memorial Hospital Los Banos

Position Overview:

Established to serve the needs of the growing Westside community in Merced County, Memorial Hospital Los Banos (MHLB) opened its doors on Sept. 5, 1967. Today, MHLB is accredited by the Joint Commission on Accreditation of Healthcare Organizations and operates as a non-profit, general care medical center with 26 active physicians on staff.​​​​​​​
A mission answers the question “Why do we exist?” Our mission statement: Memorial Hospital Los Banos provides high quality compassionate care and exercises prudent fiscal responsibility.

Works as part of the operations leadership team to accelerate the measurable and continual progress in meeting the organization's quality objectives.
Works collaboratively with Medical Directors, Chief Medical Officers (CMOs), operational executives, and quality and patient safety executives to develop the strategic plan, set direction, and evaluation of clinical quality management programs. Responsible for overall management of activities and resources as related to planning, budgeting, organizing, staffing, directing, monitoring, controlling, and coordinating the work efforts of the department. Provides direction and ensures effective implementation of the Quality Improvement Program for acute services. Assimilates information to proactively develop quality activities aligned with (affiliate name) strategies and values. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on aspects of the quality program to develop and influence improvement strategies.

Has significant responsibility for working with the organization to pursue operational improvements and efficiencies, supporting the development and implementation of clinical assessment/process improvement and redesign. Pursues opportunities for work that adds value and eliminates waste and redundancy for the organization to help achieve and retain optimal quality outcomes.

Job Description:

EDUCATION:

• Bachelor's: Management, public health, nursing, business administration, organizational leadership or related field.

CERTIFICATION & LICENSURE:

• RN-Registered Nurse of California
• OR MD-Medical Doctor
• OR PharmD-Pharmacist
• OR PA-Physician Assistant
• OR NP-Nurse Practitioner

TYPICAL EXPERIENCE:

• 12 years recent relevant experience.

JOB ACCOUNTABILITIES:

Quality Improvement Functions.

• Develops, implements, and provides coordination of affiliate's Continuous Quality Improvement (CQI) Program. Utilizes observational skills and other appropriate data sources to gather information on clinical and operational processes to improve the organization’s processes, recommend solutions, and implement action plans.

• Integrates CQI with the medical staff structure and activities and implements coordination of the performance improvement program across all departments and including the Board of Directors.

• Provides education and direction to hospital management and medical staff leaders in CQI concepts and techniques and works to continuously integrate quality improvement functions across departments and with medical staff and between the medical staff and the patient service departments.

• Provides independent project leadership on assigned projects, including focus on coordination of initiatives related to process improvement and redesign.

• Deconstructs processes, assesses operations, and implements recommendations for developing best practices for implementation and develops baseline and ongoing measurements to track improvement.

Patient Safety Functions.

• Plans, organizes and coordinates all aspects of the Patient Safety program within the facility. Is responsible for developing and maintaining a comprehensive patient safety program including identification, evaluation and coordination of corrective action implementation related to identified safety issues in conjunction with the risk management leadership.

• Maintains knowledge of regulatory/accrediting agencies, statutes and reporting requirements.

• Collaborates with Risk Management leadership in identification and reporting of real and potential patient safety issues.

• Maintains direct responsibility to make timely reports to leadership, medical staff, administration, hospital departments and committees, as appropriate.

• Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce harm/potential harm associated with the provision of patient care. Acts as the facility Patient Safety Officer.

• Is responsible for the facilitation and conduct of the harm measurement system for safety events. Manages the recording and reporting of harm events utilizing the proscribed tools and methods.

• Coordinates with the risk management leadership on risk management and patient safety activities which include but may not be limited to coordinating those systems necessary for identification, evaluation, monitoring, reduction and/or elimination of patient harm, including the conduct of root cause, apparent cause, and common cause analyses based on patient harm/patient safety/risk management issues/events.

• Provides counseling and education to the administrative and management staff, clinical personnel, and medical staff members related to the patient safety day-to-day operations.

• Manages analysis and reporting of patient safety data to the organization, leadership, and Sutter Health.

Accreditations/Regulatory Functions.

• Oversees organizational compliance with regulations governing rules of accrediting bodies as it relates to acute care hospitals & related services. Develops and implements strategies that support continuous survey readiness. Establishes, and defines program parameters, and monitors results of quality management standards in conjunction with leadership.

• These responsibilities include:

• Facilitates preparation of surveys and participates as administrative liaison in all surveys effecting licensure and/or accreditation.

• Maintains knowledge in Joint Commission, Centers for Medicare and Medicaid Services (CMS), State and other applicable requirements and provides education to administration, management, staff and medical staff on new requirements.

• Coordinates the accreditation and licensure activities for affiliate including ongoing readiness activities and participation in mock surveys.

• Completes self-assessment tools required by Joint Commission on an annual basis in coordination with organizational leadership.

• Facilitates the development of action plans to mitigate survey findings and submits to the appropriate agency upon review and approval of leadership.

• Manages accreditation readiness staff.

Medical Staff Peer Review Functions:

• Facilitates and collaborates with medical staff leadership and peer review staff to coordinate all aspects of the affiliate. Physician Peer Review Program. Functions in a collaborative manner with all hospital disciplines impacted by the peer review process.

• Responsibilities include assisting in the monitoring, collection, analysis, security and reporting of all pertinent data findings related to physician performance as determined by the individual medical staff departments. Identifies opportunities to improve patient outcomes, safety and quality, and actively supports the elements of extending excellence.

• Assists medical department leadership in determining criteria for conducting, ongoing professional practice evaluation (OPPE), triggers indicating need for, focused professional practice evaluation (FPPE) and on-going clinical monitors.

• Assists the medical staff in identifying data to be collected, method of data abstraction and reporting format. The type of data to be collected is determined by individual departments and approved by the organized medical staff and governing body.

• Performs on-going physician performance monitoring ~ to include data collection and trending physician clinical performance with an internal reporting system including dissemination of information to medical staff.

• Validates peer review data ensuring completeness and accuracy on an on-going basis to support patient safety organizational activities.

• Prepares and participates in peer review committees in collaboration with department chairs.

• Participates in preparation physician re-credentialing reports.

• Facilitates FPPE, focused professional practice evaluation process as defined by, and the direction of the organized medical staff leaders.

• Attends medical staff meetings to facilitate integration of functions across both medial staff and hospital departments and/or support the medical staff peer review and the hospital’s performance improvement processes.

Medical Staff Office:

• Provides leadership oversight to the medical staff services manager/department in conjunction with the affiliate Chief Medical Executive.

• Assures medical staff credentialing activities support patient safety and all applicable requirements per bylaws, rules and regulations.

• Assures adequate and competent support of medical staff meetings.

• Assures OPPE process is effective and maintained on schedule.

Evidence Based Leadership:'

• Evaluates effectiveness, timeliness, accuracy, and appropriateness of staff functions by reviewing activities with each employee on an ongoing basis. Understands the roles and responsibilities of each position/function within the Integrated Quality Services Department and provides direct supervision to IQS staff.

• Conducts interviews and hires for vacant positions within the department.

• Completes performance evaluations for departmental staff in a timely manner, reflecting an accurate assessment of employee performance in comparison with established standards.

• Assures that all personnel actions are in conformance with the organization’s Personnel Policies and Procedures.

• Establishes schedules of work that ensure productive use of time and meet the requirements for each job function and the needs of the organization and Integrated Quality Services Department customers. Reviews and approves all time sheets bi-weekly.

• Prepares and monitors a budget for the Integrated Quality Services Department that encompasses all direct report functions within the department reflecting the mission and goals of the organization.

• Maintains confidentiality of all activities within the department especially to ensure compliance with California Statute 1157 and will not voluntarily divulge any protected information.

• Builds and maintains effective working relationships with others. Deals with patients, physicians, employees, and visitors in a friendly and cordial manner, in person or on the telephone, thus promoting a positive service image.

DIRECT PATIENT CARE HIPAA:

• Maintains strictest confidence as required under Health Insurance Portability and Accountability (HIPAA) for all patient Protected Health Information (PHI).

• All PHI is protected from accidental or intentional, inappropriate disclosure one hundred percent (100%) of the time.

SKILLS AND KNOWLEDGE:

• Leadership and management skills required. Demonstrated leadership skills in a complex environment with the ability to plan, set and accomplish multiple objectives. Proven ability to select, lead, motivate and grow professional staff.
• Expert skills in verbal and written communication when stakes are high.
• Ability to work collaboratively with physicians, hospital executives, health plan personnel, governmental personnel, and colleagues in the foundation and Sutter Health.
• Ability to prioritize, make decisions and set clear expectations for others.
• Must be computer literate, especially with spreadsheet and word processing software.
• Must have detailed knowledge of the clinical, business, operational and financial, and regulatory/compliance aspects of commercial and governmental capitated health care programs.
• Must be well versed in medical foundation and medical group organization and structure.
• Knowledge of state and federal regulations governing immunity for peer review confidentiality.
• Working knowledge of Total Quality Management (TQM)/Continuous Quality Improvement (CQI) in clinical settings.
• Knowledgeable about health care law, regulations, accreditation requirements and clinical standards of practice.
• Understand business planning including analysis, statistics, budgeting, feasibility studies and implementation.
• Ability to function independently with minimal management.
• Understands risk management principles and process.

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

As Needed

Benefits:

Yes

Unions:

No

Position Status:

Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

0

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $73.25 to $117.20 / hour

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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