Director Clinical Quality and Patient Safety - Sharp Tri-City Medical Center at Sharp HealthCare in STCMC Tri-City Medical Center Main Campus - 4002 Vista Way

Job description

• The Director Clinical Quality and Patient Safety provides strategic oversight, direction, and integration of clinical quality and patient safety initiatives for Tri-City Medical Center. Reporting to the Chief Medical Officer, the Director partners with executive leadership to foster a culture of safety, reduce clinical risk, and oversee complex data management systems that support execution necessary to achieve top-decile clinical outcomes. The Director is also responsible for the effectiveness and efficiency of adverse event reporting, and report distribution. This individual ensures absolute compliance with state and federal reporting mandates (HCAI, TJC, CMS) and leads the organization in achieving high-reliability performance through advanced clinical analytics and performance improvement methodologies.

Responsibilities

• The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.
• 1. Directs the entity's Quality Assessment and Performance Improvement (QAPI) program and patient safety culture, positioning the Quality Department as the central hub for strategic program development.
• 2. Collaborates with Clinical Effectiveness and the executive team to establish and execute multi-year strategic roadmaps for quality, patient safety, and performance improvement.
• 3. Plans and directs the operational, budgetary, and personnel activities for Quality, Patient Safety, and Clinical Risk to ensure alignment with organizational objectives.
• 4. Leads performance improvement initiatives using Lean, Six Sigma, or similar methodologies to close performance gaps in external ratings and publicly reported measures.
• 5. Directs and serves on committees addressing Quality, Patient Safety, and Clinical Risk, and coordinates action plans with key healthcare professionals. Provides reports and presentations to the Board of Directors, Executive Council, Directors and Medical Staff.
• 6. Oversees the collection, analysis, monitoring, and reporting of clinical outcomes and performance data; identifies trends and ensures decisions and corrective actions are based on verifiable, measurable criteria.
• 7. Ensures compliance with applicable federal and state requirements and accrediting standards, including TJC, CMS, HCAI, and the State of California pertaining to Quality and Patient Safety.
• 8. Oversees reporting of required and voluntary quality measures, monitors external ratings, promotes evidence-based practices and infection prevention processes. This includes reporting of CMS IQR, core measures, TEAM, promoting interoperability and Leapfrog; Advises the Chief Medical Officer and Chief Nursing Officer of relevant requirements and performance trends.
• 9. Oversees adverse event and physician peer review reporting for external agencies and organizational governance bodies, and partners with physician leadership to ensure timely resolution of clinical concerns.
• 10. Serves as the designated Patient Safety Officer and primary liaison to Sharp HealthCare Legal and Risk Management regarding high-exposure events and mitigation strategies.
• 11. Partners with Nursing, ancillary services, Medical Staff, and other stakeholders to identify improvement opportunities, support monitoring activities, provide education, and implement action plans.
• 12. Leads or supports regional, national, and other assigned quality-metric initiatives.
• 13. Serves as a core member of the Executive Leadership Team and participates in the Administrator on Duty (AOD) rotation.
• 14. Performs other duties as assigned.

Requirements

• Master's Degree in nursing or health related field from an accredited university.
• 5 Years clinical healthcare experience.
• Prior management experience.
• Experience with clinical data analysis and presentation.
• Experience with nursing quality management, systems performance improvement, and/or efficiency programs.
• Possess knowledge of the business of health care along the continuum of care, clinical decision support data analysis/syntheses and quality improvement, regulatory and legislative issues, required.
• Strong organizational, communication and interpersonal skills, both verbally and in writing required. Personal initiative and the ability to lead people, especially in relationship to the medical staff, along with exceptional and demonstrated relationship building and personal interaction skills with individuals in diverse educational and professional roles is required.
• Demonstrated leadership ability working with all levels, required.
• Demonstrated initiative and problem solving skills, using sound judgement, required.
• Knowledge of regulatory quality indicators, preferred.
• Knowledge of state and national regulations, standards, and operating definitions for evidence-based measures, required.
• Must also have the ability to train and educate others based on relevant information gained through data analysis, required.
• Understands concepts of reliability, outcomes management and fiscal integration, required.
• Able to multi-task in an organized efficient manner, required.
• Self-directed learner and professional. Enthusiastically seeks ways to improve patient care and motivates others to participate in improvement activities.
• Computer operation skills, understanding of statistics, spreadsheets and database systems, required.
• Experience conducting/participating in Root Cause Analysis.
• Experience working with Quality Net, NHSN, CALNOC, NDNQI, HSAG, TJC, RL, and Cerner.
• Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality
• Lean Six Sigma and DFSS Certification - Various-Employee provides certificate

Skills

Required

• Quality improvement
• Regulatory and legislative issues
• Self-directed learner and professional

Preferred

• Lean Six Sigma and DFSS Certification

Benefits

• $64.610 - $86.140 - $107.670
• The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.