CommonSpirit Health
Director of Quality – CommonSpirit Health
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Director Quality
role at
CommonSpirit Health .
This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and for identifying opportunities for improved patient care, incorporating evidence-based practices, and improving patient outcomes. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.
Responsibilities
Establish performance improvement goals annually with relevant stakeholders. Ensure the Performance Improvement and Patient Safety plans and hospital‑focused projects for the year are implemented and their effectiveness evaluated annually. Develop and implement processes and formats to support data collection, aggregation, analysis, and action planning. Ensure data is managed appropriately and disseminated to appropriate leadership staff. Provide leadership in developing quality improvement and patient safety training programs, and coach organizational clinical/service lines and operational/support departments in quality improvement principles.
Oversee the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, summons and complaints, and coordination of legal documents related to hospital liability). Participate in system office initiatives and programs to mitigate risks identified at other hospitals, reducing costs, adverse patient outcomes and promoting safer patient practices and care.
Collaborate with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing focused practitioner evaluation.
Provide leadership and be responsible for accreditation and regulatory survey readiness. Oversee mock survey tracers to assess readiness. Provide education to staff and providers on regulatory compliance. Organize staff to develop responses to survey deficiencies and submit responses to the appropriate accreditation or regulatory agency.
Qualifications Education and Experience
Bachelor's degree in a healthcare‑related field or five (5) years of related job or industry experience in lieu of a degree.
Minimum of five (5) years of progressive management responsibility in an acute care setting, two (2) of which is related to managing an organization’s Quality Improvement Program. Minimum of two (2) years of clinical, patient care experience or equivalent. Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale. Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN). Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services.
Licensure
Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.
Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Required Knowledge, Skills, Abilities, and Training
Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities.
Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.
Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN).
Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services.
Experience with the event reporting process, root cause analyses, and event investigation/review.
Ability to manage collaboratively, coach others, delegate effectively, reward contributions, define clear roles and responsibilities, set goals, lead initiatives, and adjust plans as necessary.
Ability to anticipate, recognize and deal effectively with existing or potential conflicts at the individual, group, or situation level.
Ability to identify opportunities and take action to build strategic relationships across areas and teams to achieve business goals.
Excellent communication skills (oral and written), presentation style, including ability to concisely present data to leaders, clinicians and staff at all levels of the organization.
Where You'll Work Dignity Health Mercy San Juan Medical Center is a 384‑bed not‑for‑profit Level 2 Trauma Center located in Carmichael, California. It serves north Sacramento County and south Placer County for over 50 years. The facility is one of the area’s largest medical centers and also one of the most comprehensive. Mercy San Juan Medical Center is a Comprehensive Stroke Center and a Spine Center of Excellence, and has received the Perinatal Care Certificate of Excellence and a Certificate of Excellence for Hip and Knee Replacements.
Pay Range $66.26 – $98.56 per hour.
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Director Quality
role at
CommonSpirit Health .
This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and for identifying opportunities for improved patient care, incorporating evidence-based practices, and improving patient outcomes. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.
Responsibilities
Establish performance improvement goals annually with relevant stakeholders. Ensure the Performance Improvement and Patient Safety plans and hospital‑focused projects for the year are implemented and their effectiveness evaluated annually. Develop and implement processes and formats to support data collection, aggregation, analysis, and action planning. Ensure data is managed appropriately and disseminated to appropriate leadership staff. Provide leadership in developing quality improvement and patient safety training programs, and coach organizational clinical/service lines and operational/support departments in quality improvement principles.
Oversee the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, summons and complaints, and coordination of legal documents related to hospital liability). Participate in system office initiatives and programs to mitigate risks identified at other hospitals, reducing costs, adverse patient outcomes and promoting safer patient practices and care.
Collaborate with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing focused practitioner evaluation.
Provide leadership and be responsible for accreditation and regulatory survey readiness. Oversee mock survey tracers to assess readiness. Provide education to staff and providers on regulatory compliance. Organize staff to develop responses to survey deficiencies and submit responses to the appropriate accreditation or regulatory agency.
Qualifications Education and Experience
Bachelor's degree in a healthcare‑related field or five (5) years of related job or industry experience in lieu of a degree.
Minimum of five (5) years of progressive management responsibility in an acute care setting, two (2) of which is related to managing an organization’s Quality Improvement Program. Minimum of two (2) years of clinical, patient care experience or equivalent. Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale. Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN). Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services.
Licensure
Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.
Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Required Knowledge, Skills, Abilities, and Training
Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities.
Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.
Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN).
Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services.
Experience with the event reporting process, root cause analyses, and event investigation/review.
Ability to manage collaboratively, coach others, delegate effectively, reward contributions, define clear roles and responsibilities, set goals, lead initiatives, and adjust plans as necessary.
Ability to anticipate, recognize and deal effectively with existing or potential conflicts at the individual, group, or situation level.
Ability to identify opportunities and take action to build strategic relationships across areas and teams to achieve business goals.
Excellent communication skills (oral and written), presentation style, including ability to concisely present data to leaders, clinicians and staff at all levels of the organization.
Where You'll Work Dignity Health Mercy San Juan Medical Center is a 384‑bed not‑for‑profit Level 2 Trauma Center located in Carmichael, California. It serves north Sacramento County and south Placer County for over 50 years. The facility is one of the area’s largest medical centers and also one of the most comprehensive. Mercy San Juan Medical Center is a Comprehensive Stroke Center and a Spine Center of Excellence, and has received the Perinatal Care Certificate of Excellence and a Certificate of Excellence for Hip and Knee Replacements.
Pay Range $66.26 – $98.56 per hour.
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