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Director-Quality/Patient Safety Officer - Quality Improvement

Company: Eisenhower Medical Center
Location: Rancho Mirage
Posted on: May 14, 2022

Job Description:

Administration (Central Valley II Clinics) Administration (Clinic Division) Administration (ELCCC) Allergy-Immunology (Kiewit) Ambulatory Patient Advance Access Anesthesia Breast Center (ELCCC) BSCC-Admin Cafeteria Coffee Shop Cardiac Surgery Admin Cardiology Cardiothoracic Surgery Clinic Case Management Social Services Central Sterile Processing Centralized Monitoring Unit (CMU) Chaplaincy Services Child Diagnostic Clinic Billing Services Clinic Division Float Pool Clinical Documentation Improvement CMS Quality Payment Program COVID-19 Research Trial Cytology Dermatology Mohs Clinic Dialysis E365 Primary Care (Argyros) E365 Primary Care (North Palm Desert) EDCC Other Tests EDOC Clinic (Rancho Mirage) EDOC Clinic (Sunrise) EDOC Pain Clinic (Hope Square) EDOC Pain Management (South Palm Canyon) EDOC Physical Therapy (Argyros) EDOC Physical Therapy (Rinker) EDOSC PAT EDOSC Surgery Emergency Room Employee Health Endocrinology (Rancho Mirage) EVS (Professional Office Buildings) Finance - Clinic Division Finance-Corporate Foundation GI Lab Histology Hospitalists Program Human Resources Information Systems Infusion Center (Infectious Disease) Intensive Care Units Interventional Radiology Legal Department Main Infusion Medical Records Medical Surgical 2E Medical Surgical 3E Medical Surgical 4E Neonatal ICU Level II Nurse Magnet Initiative Nursing Nursing Administration Nursing Education OB-ED (Obstetrics Emergency Dept) Occupational Health (Cathedral City) Occupational Therapy DHOC Oncology Medical Transport Organizational Transformation Ortho Service Line Parkinson's and Movement Disorders Center (Probst) Physical Therapy DHOC Pre Op Interview Office Primary Care (Monterey/Country Club) Primary Care (North Palm Canyon) Primary Care (Rimrock) Primary Care Center for Family Medicine (Argyros) Primary Care Center for Internal Medicine (Bannan) Primary Care Concierge (Monterey/Country Club) Primary Care Concierge (Probst) Primary Care Internal Medicine Residency (Cathedral City) Applicants will only be eligible to proceed with the hiring process if the applicant: (1) is fully vaccinated and can provide proof of vaccination; or (2) qualifies for a medical or religious exemption that can be accommodated by Eisenhower Health.Director-Quality/Patient Safety Officer - Quality Improvement Job Description: A brief statement of the position, including the general job duties. The Director of Quality is responsible for leading the development of a culture of safety and measures of quality of care. Identifies opportunities and strategies for performance improvement. Oversees the health system's patient safety program and the Pay for Performance/Reporting requirements. Reports to Administrative Director of Quality and Performance Improvement Infection Preventionists, Quality Analysts, Quality Program Managers Ages of Patients None Minimal/ No Potential Qualifications Education Required: Masters Degree in Nursing or other healthcare related field. Licensure/Certification For Registered Nurses - Required: -California RN License, Certified Professional in Healthcare Quality (CPHQ) Experience Required: Minimum five years working in healthcare Quality Improvement or related field. Specific Skills, Knowledge, Abilities Required Computer skills, to include data entry, spreadsheets, graphics, information systems. Ability to collect, analyze and disseminate data, including financial and statistical data. Knowledge of performance improvement tools, and the ability to use them effectively. Excellent verbal and written communication and interpersonal skills; experience presenting data and information to physicians and other clinical staff as directed. Experience working with clinical outcomes data systems and resource management. Ability to set goals and work independently and efficiently with minimal supervision; ability to prioritize fluctuating workload and times to meet position demands. Ability to work in a fast-paced environment and manage multiple meetings and projects. Knowledge of regulatory standards including Joint Commission, Medicare (CMS) and Title 22 (state) requirements. Data collection and analysis. Essential Job Specific Responsibilities Initiates and oversees the development of a comprehensive safety / quality / performance improvement program working in collaboration with nursing and medical staff leadership. This is inclusive of the analysis and trending of data related to initiatives Provides strategic oversight of proactive and reactive patient safety activities including RCA, FMEA and Sentinel Event Alerts in regards to facilitation of process planning. Implementation and evaluation of effectiveness of process changes Develops and implements the Strategic Plans for Quality and Patient Safety annually Supports the medical staff peer review process, OPPE and credentialing Provides oversight of the accreditation and licensing survey readiness, ensuring that education is provided to Administration Leadership and staff on regulatory compliance Oversees mock survey tracers of the organization to assess survey readiness (also for all licensing inspections of new services) in collaboration with the program manager of regulagtory and licensing Collaborates with the Program Manager of Regulatory and Licensing to complete action plans / responses to accrediting / regulatory surveys Oversees collection, submission of data reported internally and to external agencies (required or optional). Reports to appropriate organization entities Oversight of all licensing functions, applications for additional services, change in beds, services, etc Coordinates the Quality/Patient Safety Council, in collaboration with the Council Chairperson. Communicates pertinent reports to the medical staff and organization leaders Works closely with the Medical Staff Quality Analysts to ensure that agendas and reports for the medical staff QA&I and Committee meetings are complete and prepared in a timely manner. Leads and supports performance improvement teams using lean concepts Recommends and facilitates change within the organization to improve patient safety, based on identified risks. Utilizes the hospital's performance improvement model, to coordinate the redesign of the process and/or underlying systems to minimize the risk of that undesirable variation or to protect patients from the effects of that undesirable variation. Follows critical analysis and identification of failure mode (process variation) methodology Supports and encourages error reporting throughout the organization through a non-punitive error reporting systems Measures and evaluates effectiveness of quality and patient safety programs using established goals and prepares an annual report for the Governing Board

Keywords: Eisenhower Medical Center, Palm Springs , Director-Quality/Patient Safety Officer - Quality Improvement, Executive , Rancho Mirage, California

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