The Director – Quality and Risk Management, serves as a regulatory accreditation expert and ensures ongoing compliance with federal/state regulatory expectations and accrediting organization requirements. Develops and leads the execution of the hospitals ongoing survey readiness strategy to include internal readiness audits, written reports of out of compliance findings, and oversight of action plans to mitigate findings under the direction of the Qu – Quality and Risk Management. Reviews all action plans, 2567’s and Measures of Success prior to submission to any regulatory or accreditation organization and will work with the hosptial leadership to ensure initial compliance and ongoing sustainment as directed. Acts as a resource for CMS regulatory and outcomes monitoring programs; for federal reporting system(s); and will create, distribute and implement tools and other resources to the facilities. Serves as a subject matter expert in clinical practice and patient rights regulation and accreditation standards.

• Serves as the regulatory and accreditation expert, especially in clinical practice and patient rights subject matter, and ensures ongoing compliance with federal/state regulatory expectations and accrediting organization requirements.
• Ensures department is meeting established goals and objectives; as well as, performance improvement initiatives in support of overall goals of the PMH Quality Assurance/ Performance Improvement program. Establishes and maintains appropriate monitoring and control systems to ensure goals and objectives are achieved.
• Provides oversight to the development, implementation, and evaluation of the overall quality and patient safety programs at the hospitals. Oversees the local Manager – Quality and Risk to collect and analyze data; identify trends; prioritize, recommend, and provide oversight for improvements; decrease duplication, and ensure any other relevant regulatory or reporting organizations compliance.
• Maintain current knowledge of the Joint Commission, State, and any other relevant regulatory or reporting organizations’ standards on quality indicators and certification processes. Supports accreditation process including triennial surveys, random unannounced surveys, and complaint surveys.
• Develops and implements facility continual survey readiness plan; conducts internal audit process to measure survey readiness; provides survey rapid response assistance as needed; assists with survey response development; oversees action plan compliance. Knowledge of accreditations, CDPH/CMS surveys, Medicare Quality-Based Payment Reform (VBP, HAI, MRRP, MSPB) QIO interaction, Clarity report mitigation, RCA conduction, work with Medical Staff on Peer Review Process

REQUIRED QUALIFICATIONS:

• Active, current, and unencumbered Licensure as a Registered Nurse in the State of California
• Graduate of an Accredited School of Nursing
• AHA Basic Life Support
• Ability to read, write and communicate effectively in English
• Ability to work variable shifts including evenings, nights, weekends, and holidays
• Ability to maintain flexibility and composure in a constantly changing environment
• Hospital Fire and Life Safety Card (Los Angeles City Employees only)
• Bachelor’s degree or equivalent work experience in relevant healthcare clinical area.
• Seven (7) years of healthcare experience with two (2) years of experience in leading Quality and/or Risk Management
• Demonstrates ability to develop and lead employees at all levels including key leadership; demonstrates ability to get things done through influence rather than direct management control
• CPHQ, CHCQM or equivalent within one year of employment
• Excellent verbal and written communication skills
• Quality Measure Performance Improvement experience
• Computer Literacy and Proficiency in MS Office, specifically Word and Excel
• Ability to maintain flexibility and work well in a fast paced, constantly changing environment
• Ability to establish and maintain effective working relationships across the organization

PREFERRED QUALIFICATIONS:

• Bachelor of Science in Nursing
• Bilingual skills to communicate effectively with patients and families
• MN/MSN, MPH, MHA or MBA or related area
• Certified in Health Care Risk Management (CPHRM) (ASHRM)
• Registered Nurse or other clinical license
• Experience within a multi-site, multi-state healthcare system

Please refer the Job description for details