Director of Quality and Regulations

Overview

Bargaining Unit: Non Represented - Director

Rate of Pay: $185,931 + DOE annually

Summary

Provides leadership in the promotion of a culture of safety, and the measurement of the quality-of-care identifying opportunities, and strategies for performance improvement (PI). Directs and coordinates licensing, accreditation, policy, and regulatory affairs initiatives, and assures compliance. Provides oversight and direction for risk management, infection prevention, patient safety, high reliability, medical staff peer review, physician quality reporting, patient satisfaction, performance improvement, data management, and the grievance/complaint process.

Serves as the Discrimination Officer.

Essential Duties and Responsibilities

• Initiates and oversees a comprehensive patient safety/quality/performance improvement program inclusive of the analysis and trending of data related to initiatives.
• Responsible for and ensures annual review, and approval, of the QA/PI Plan, Risk Patient Safety Plan; and the Infection Control Plan, developing hospital-wide compliance, assuring follow-up and responses in a timely manner.
• Serves as the Discrimination Officer following the Equal Opportunity Act and the Patient Bill of Rights and Responsibilities by ensuring equal access to healthcare, prohibiting discrimination, and requiring equitable treatment for all patients, regardless of their background.
• In conjunction with the Medical Staff, and system leadership, directs and coordinates quality/performance improvement/risk/patient safety/high reliability/infection prevention/patient experience/quality data management initiatives.
• Provides oversight of patient safety activities, including root cause analysis/event analysis/case reviews, in regard to the facilitation of process, planning, implementation, communication, and evaluation of effectiveness of process changes.
• Prepares reports to Board of Directors and Medical Staff Quality Committee regarding Risk/Patient Safety, Service Excellence, and Quality/Performance Improvement Program.
• Coordinates the Board Quality Committee and Medical Staff Quality Committee quarterly meeting agenda and attachments.
• Regularly communicates PI and quality/patient safety activities to leadership and staff.
• Promotes interdepartmental, and Medical Staff collaboration, to develop a cooperative effort in the endorsement of a patient safety, risk mitigation, and quality management focused program utilizing high reliability principles.
• Implements organizational-wide programs, policies, and procedures to ensure the District's compliance with applicable federal and state laws and regulations, such as those for CMS, ACHC, CDPH, HCQC, and other regulatory agencies.
• Maintains awareness of healthcare laws and regulations, keeping abreast of current changes that may affect the organization. Shares with applicable Director/Managers and Medical Staff, and monitors compliance.
• Oversight for the development and monitoring of unit/department specific QA/PI plans, initiating appropriate action to improve outcomes.
• Responsible for the Grievance/Complaint program related to quality-of-care concerns, ensuring hospital-wide compliance with follow-up, and timely patient responses.
• Integrates High Reliability organizational principles, in every aspect of Quality & Regulations, to mitigate risks.
• Collaborates with Directors/Managers, and Medical Staff, regarding patient satisfaction results, and develops plans for improvement.
• Establishes mechanisms to assess and document regulatory compliance and serves as the primary liaison with regulatory agency officials.
• Serves as the primary contact with regulatory agencies related to surveys and licenses.
• Responsible for the following contracts:
  Beta Healthcare Group;
  Alliant Insurance; RL Datix;
  Press Ganey; QCentrix; ASM MD Stat;
  Health Services Advisory Group (HSAG);
  Quality Improvement Organization (QIO) related contracts;
  Collaborative Healthcare Patient Safety Organization (CHPSO), Sierra Collaborative external peer review, and other Quality related contracts.
• Demonstrates a passionate commitment to open communication and leadership following communication principles and System…