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Department

Quality Management

The Director of Quality and Safety is responsible for providing leadership, direction, and implementation of all quality/performance improvement (PI) activities to ensure compliance with regulatory and accrediting body requirements and organizational goals, encompassing the performance of the medical staff, nursing staff, and support services. The Director collaborates with the medical staff to ensure that the performance improvement programs effectively monitor, assess and continuously improve the quality of care and service provided. The Director executes strategic planning and implementation of improvements to reach milestones in Quality and Safety. The Director, under the direction of the VP, Quality and Risk Management, will work with all levels of the organization to position Salinas Valley Health to achieve excellence in quality and safety and provide leadership and direction to assess, improve, monitor, and report the safety, effectiveness, efficiency, patient centeredness, equity, and timeliness of healthcare and services for all patients. The position reports directly to the VP, Quality and Risk Management.

1. Oversees public reporting for all required and voluntary reporting to federal and state regulatory and accrediting agencies. Ensures accurate and timely completion of all data abstraction/data entry for all required and voluntary reporting to federal and state regulatory and accrediting agencies. The Director

also works closely with all levels of the organization to implement interventions that improve patient outcomes.

2. In collaboration with the Vice President, builds a patient safety culture throughout the institution. Coordinates activities of the Quality and Safety Committee. Reports organizational PI data to the Quality and Safety Committee and the Quality and Efficient Practices Committee of the Board of Directors. Works closely with the VP, Quality and Risk Management to develop and implement action plans after sentinel events are reviewed by the Patient Safety Events Committee. Works closely with Risk Management to ensure SVH physicians and staff are aware of CANDOR (Communication and Optimal Resolution) principles.

3. Ensures and expedites process of event management including proactively identifying risks, encouraging accurate adverse event reporting and thoughtful analyses of safety events and near-misses, facilitating SVH-wide learning, and facilitating system and local improvements required for safe care.

4. Oversees the Safety Event Classification and Cause Analysis program and works with the Patient Safety Manager to calculate and report to the Quality and Efficient Practices Committee of the Board a serious Safety Event Rate.

5. Develops, prioritizes, directs, and/or coordinates the deployment of Quality and Safety resources across SVH. Facilitates a structured problem-solving approach to maintain or improve performance. May involve data collection, meeting facilitation, documenting decisions; research/benchmarking, organizing

pilots for new processes, developing timelines. Works with and/or facilitates interdisciplinary PI teams ensuring that PI team activities are directed toward analysis of data, with a focus on improvement of processes. Oversees staff that drive improvement efforts for SVH that are trended through adverse event

reviews, medical staff outcomes data, and aligned efforts with hospital leadership.

6. Coordinates compliance with CMS QAPI conditions of participation and Joint Commission Improving Organizational Performance (IOP) standards. Works closely with IT and other departments in the development of eCQM and other reporting measures. Works closely with the Director of Accreditation and Regulatory to ensure timely reporting of sentinel events and to provide and speak to quality data when regulatory agencies are onsite. Responsible for maintaining compliance with all Performance Improvement Chapter standards as set by Joint Commission

7. Directs and manages institutional projects and improvements designed to improve national rankings in Quality and Safety including, but not limited to: inpatient/ outpatient core measures reporting to Joint Commission and CMS, AHRQ Patient Safety Indicators, CMS Hospital-Acquired Conditions, and others. Supports database management including Vizient Quality and Accountability Scorecard, LeapFrog, QualityNet, CCORP, STS and American College of Cardiology, as well as timely data submission.

8. Assists in monitoring and evaluating patient care in relationship to best practices; recommends modifications to care and facilitates performance improvement identifying trends, variances, opportunities for improvement, utilizing aggregated data and information. Collaborates with key stakeholder groups to ensure consistent patient-centered care

9. Provides education and training related to PI activities, process and methodology to staff and physicians. Ensures services are in in place to address quality and safety program needs. Establishes integrated structures to assess clinical department/ program effectiveness. Supervises and fosters teamwork,

culture of safety, collegiality, and productivity.

10. Fields feedback/issues/concerns from medical staff, administrative and hospital staff. Creates, tracks, and communicates quality and safety process and outcome metrics. Ensures that quality and safety program needs are taken into account in all key decisions.

11. Maintains and updates the Organizational Performance Improvement Plan, the Annual Quality and Safety Report, the Health Equity Disparity Reduction Plan, and any other quality and safety plans that need review annually.

12. Serves as a positive role model and effective liaison for the Hospital.

13. Performs other duties as assigned.

Job Requirements

Education: Bachelor's Degree in Nursing or other appropriate healthcare field required. Master's preferred. Certified Professional in Healthcare Quality (CPHQ) required. New hires and transfers have one (1) year for hire/transfer to obtain.

Licensure: Licensed as a Registered Nurse in the State of California or other appropriate healthcare training license required.

Experience: Five (5) years' experience in quality in an acute care setting with progressive leadership responsibility in healthcare quality/performance improvement; thorough understanding of Joint Commission standards, state and federal standards, value-based purchasing initiatives, readmission reduction and hospital acquired conditions programs, core measures and HCAHPS; excellent analytical, PI methodology, computer, organizational, critical thinking and team facilitation skills; expertise in data management, presentation and analysis; experience in implementation and management of a healthcare quality program(s).

Management Skills

Budgetary preparation, monitoring and control
Human Resources management
Management and supervisory theories, principles, practices, techniques and methods

Interpersonal Skills

Communicate effectively both orally and in writing to diverse groups and individuals Work effectively with administration, employees and medical staff
Identify and analyze complex departmental (and patient care) issues
Make independent decisions and provide counsel and advice to administration, employees and medical staff
Exercise good judgement and tact in providing leadership, guidance and assistance

Pay Range: The hourly rate for this position is $83.86 - $115.00. The range displayed on this job posting reflects the target for new hire salaries for this position.

Job Specifications

Union: Non-Affiliated
Work Shift: Day Shift
FTE: 1.0
Scheduled Hours: 40

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!