Director Quality And Patient Safety

Overview

Founded as a faith-based hospital in 1931 by the Sisters of Charity of the Incarnate Word, Dignity Health - St. Bernardine Medical Center is a 342-bed, acute care, nonprofit hospital located in San Bernardino, California. The hospital offers a full complement of services, including the Inland Empire Heart and Vascular Institute, an award-winning orthopedics program, surgical weight loss, and is an official Neurovascular Stroke Center, as designated by ICEMA. The hospital shares a legacy of humankindness with Dignity Health, one of the nation's five largest health care systems. Visit https://www.dignityhealth.org/socal/locations/stbernardinemedical for more information.

If you are committed to social justice, health equity, and prepared to deliver care in new, innovative ways, you belong with us.

We offer the following benefits to support you and your family:

• Annual Incentive (Bonus) Program.

• Matching Retirement Program.

• Pension fully funded by the Hospital.

• Tuition Assistance for career growth and development.

• Health/Dental/Vision Insurance.

• Free Membership to our Care@Work program supporting child care, pet care, and adult dependent needs.

• Employee Assistance Program (EAP) for you and your family.

• Flexible spending accounts.

• Voluntary Protection: Group Accident, Critical Illness, and Identity Theft.

• Wellness Program.

• Paid Time Off (PTO).

Responsibilities

Position Summary:

Responsible for the design, coordination, implementation and management of the Organization's Performance Improvement (PI) and Patient Safety plans. Identifies opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. 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.

Principal Duties and Accountabilities:

• Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement and Patient Safety plans and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and patient safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles.

• Oversees 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). Participates in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care.

• Collaborates 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 and focused practitioner evaluation.

• Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits 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 degree.

• Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organization's Quality Improvement Program.

• Minimum of two (2) years of clinical, patient care experience or equivalent.

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.

Special Skills 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 (e.g. state, federal, local regulations; Joint Commission, etc.).

• Experience with the event reporting process, root cause analyses, and event investigation/review.

• Experience with patient compliant/grievance investigations and prompt resolution.

• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks.

• Familiar with all legal documents related to hospital liability, including management of subpoenas, Summaries and Complaints and other related activities.

• Knowledge of processes, tools and techniques for assessing and controlling an organization's exposure to risks of various kinds; ability to apply this knowledge appropriately to diverse situations.

• Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/reward.

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