The Director, Quality 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 hospital’s Quality Assurance/Performance Improvement (QAPI) program to include working with the leadership team to proactively identify opportunities for improvement and implement mitigation strategies on an ongoing basis. The Director, Quality also ensures that an evaluation of the hospital’s Quality Assurance/Performance Improvement (QAPI) program occurs on an annual basis. Develops and leads the execution of the hospital’s 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 Hospital CEO and Corporate Vice President of Quality/Patient Safety. Reviews all action plans, 2567’s and Measures of Success prior to submission to any regulatory or accreditation organization and will work with the hospital 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 federal/state regulations, accreditation standards and CMS Pay-for-Performance programs.

• Serves as a regulatory and accreditation subject matter expert and ensures ongoing compliance with federal/state regulatory expectations and accrediting organization requirements.
• Ensures department is meeting established goals and objectives and 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 in the development, implementation, and evaluation of the quality, patient safety, and infection prevention programs at the hospitals. Oversees the Quality Coordinator 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. Oversees the Infection Control Manager to direct the management, planning, development, implementation, evaluation/continuous improvement of the infection prevention and control program across entire care continuum.
• Maintains 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. Maintains current knowledge of CMS Pay-for-Performance programs and works with the hospital’s leadership to ensure that the organization’s systems and processes are aligned with evidence based practices that attribute to quality care and increased value based purchasing incentives.
• 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:

• Bachelor’s degree in relevant healthcare clinical area
• Seven (7) years of healthcare experience with two (2) years of experience in leading Quality
• 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:

• MN/MSN, MPH, MHA or MBA or related area
• Registered Nurse or other clinical license
• Experience within a multi-site, multi-state healthcare system

Please refer the Job description for details