Director, Quality, Risk Prevention And Accreditation, System Float Pool

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Maintains responsibility for Quality Management and Risk Prevention functions. Provides overall direction, development, implementation and integration of the Quality Management program which includes compliance with all the Joint Commission, Federal, State and local reporting requirements.

Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment. Leads, develops and deploys a comprehensive, highly reliable program across the continuum of care and implements the organization's vision of excellence in clinical and quality outcomes and patient safety. Establishes a structure that supports the organization through analytics, analysis and High Reliability Organization (HRO) safety initiatives such as Culture of Safety, Just Culture and others included in strategic directives.

Works closely with the ministry leaders of quality, physician services, nursing leadership and homecare to champion communication, transparency, teamwork and a culture of safety. Supervises Infection Prevention program that is responsible for surveillance, analysis, interpretation and reporting of Hospital Acquired Infections (HAI) and infection prevention education.

Job Requirements:

Education and Work Experience:

• Bachelor's degree in a healthcare-related field, preferably Nursing, or equivalent combination of education/related experience: Required

• Master's Degree: Preferred

• Seven years' clinical experience in acute care setting, or equivalent combinations of education/related experience: Preferred

• Seven years' healthcare quality leadership, project management/lean or sigma training and experience building or leading a High Reliability Organization (HRO): Preferred

• Five years' leadership experience: Preferred

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of practice: Required

• Certified Professional in Healthcare Quality (CPHQ): Required

Essential Functions:

• Champions clinical quality performance and patient safety, to meet established patient safety, quality and compliance goals. Directs the development of programs and processes related to Quality Management.
  
  Provides education to all quality leadership and executives. Facilitates organization wide transition to a High Reliability Organization through development of policies, standards, indicators, implementation and evaluation techniques. Develops policies and procedures, monitors performance, develops and reviews metrics, assesses and prioritizes risk, and reports results to leadership. Serves as a resource to quality teams, medical staff and executives.

• Develops and maintains the quality and patient safety plans for the organization. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives. Supports organization in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees

• Collaborates with analytics teams to develop and maintain quality metrics that meet required reporting such as Electronic Clinical Quality Measures (eCQM) and more. Works with analytic team and our Electronic Health Record (EHR) vendor to apply meaningful analysis and process improvement.
  
  Knowledge leader for Value-Based Purchasing (VBP), Healthcare Associated Infection (HAI), readmissions, mortality and more for any clinical performance programs such as government or commercial pay for performance. Supports quality metrics for contracted services as needed.

• Evaluates various attributes of health care, such as safety, cost, place, treatment, and benefits as compared with standard results, for the purpose of making recommendations for improvement using standardized Performance Improvement (Pl) and Root Cause Analysis (RCA) techniques. Facilitates development of proactive programs to minimize risk. Initiates and monitors efforts to preserve evidence.

• Educates staff regarding information necessary to ensure Quality, Safety, Licensure & Accreditation. Develops and implements an ongoing preparedness for regulatory agencies' plan.

• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.