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Director of Quality

Company: Surgery Partners
Location: Bakersfield
Posted on: November 22, 2021

Job Description:

Position Summary

The Director of Quality is responsible for planning, administration, and monitoring of consistent readiness of all quality management, regulatory requirements, and quality improvement processes. The Director of Quality will oversee and coordinate all hospital efforts to monitor and maintain compliance with all regulatory, State, Federal government and The Joint Commission standards.

Work Schedule

8 a.m. to 5 p.m. Monday through Friday and occasional weekends depending on the needs of the hospital and demands of the job functions.


* Education: MSN required.* Specialized training in Performance Improvement, Quality Assessment and Assurance, and Regulatory Management required. Solid background and demonstrated record in performance improvement, quality assurance within an acute care hospital setting.* Licensure/Certification: Licensed as a Registered Nurse. Certified Professional in Health Care Quality certification and experience in Lean Concepts preferred.* Experience: Minimum of five years in as a manager or director level with a focus on quality, safety and regulatory accreditation.* Technical Skills: Proficient in computers for the following programs: Excel spreadsheets and statistical tools Midas quality management proficiency necessary; able to do word processing to create reports and communicate progress; able to independently use office equipment, fax, copier, etc. Requires the ability hear and verbalize information.* Interpersonal Skills: Must have the ability to effectively communicate knowledge and information to all hospital staff, team members, patients and families.* Essential Physical Requirements: Must be able to stand and walk for prolonged periods of time.* Essential Cognitive Abilities: Able to perform advanced calculations for budgets; to interpret rules/regulations/accrediting and licensing standards sufficiently for implementation; to maintain concentration and organize while dealing with multiple issues; and, to analyze data and formulate plan of action. Requires good communication and organizational skills, reasoning ability and good independent judgment. Requires working under stressful conditions and irregular hours and working with frequent interruptions. Must be able to do mathematical calculations (addition, subtraction, multiplication and division, including statistical methods related to performance improvement and Six Sigma quality activities).* Essential Mental Abilities: Individual must have good mental health and the ability to read, write and comprehend instructions.* Essential Sensory Requirements: Must have corrected hearing and vision within a normal range. Must be able to diplomatically respond to administrative and governing bodies, medical staff members, hospital personnel, patients and visitors. Able to collect sensory input, analyze political dynamics, and intervene.* Exposure to Hazards: Requires exposure to communicable diseases and potentially contaminated body fluids and hazardous materials. OSHA risk factor: Category I.* Other: Understands the mission and vision of the hospital. Operates within the concept of patient focused care. Evolves into an effective team member. Must adhere to dress code: good grooming and personal hygiene habits; and strict adherence to attendance policies. Maintains knowledge of and conforms to hospital policies and procedures.

Primary Duties

Quality Sciences:

* Establish and maintain quality activities in accordance with the Performance Improvement Plan. Includes a yearly evaluation of the quality program for the hospital.* Facilitate and coordinate the systematic organization-wide quality program.* Coordinate and facilitate the Performance Improvement Committee meetings and activities.* Provide to the governing board, administrative and medical staff bodies required quality reports containing findings from data collection, analysis and review activities.* Coach and facilitate chartered and needed quality team activities.* Assure that collection, assessment and analysis of data occurs for teams, selected processes studied, clinical practices, operational and clinical outcomes, and other pertinent functions.* Report data using statistical and scientific methods.* Close the loop on quality studies in a timely manner and implement a control plan to maintain the gain and prevent process or system entropy.* Coordinate entry of data into the Midas system or other spreadsheet function for analysis and reporting of variation; and, functions as a system administrator for Midas.

Compliance Activities:

* Supports compliance principles by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting in accordance with the Mission and Core Values, providing education on areas of non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements.* Ensures that the Hospital has systems in place to achieve compliance through the development of compliance management systems including training, policies, procedures, monitoring and auditing across all areas of the organization.* Assists members of the leadership team in adopting a culture of compliance in their daily operations.* Identifies areas of risk for compliance deficiencies and develops, implements, tracks and reports on work plans for correction and adherence to policies and standards.* Participates in the development and implementation of audits for internal, regulatory and health plan compliance.* Intervention and process development based on audit deficiencies which may include identification of needed policy development and education, procedures and regulations interpretation and application. This individual will provide leadership with the regulations and requirements.* Works with the Education Department on compliance curriculum to ensure all corporate requirements are being met.* Provides/facilitates mandatory annual training of all physicians and coding staff.* Acts as the internal expert on regulatory compliance - remaining up-to-date on new regulations and work with Executive Leadership to implementation strategies as required.* Responsible for communicating all requirements regarding background and compliance checks.* Works with leadership of the various functional areas to ensure all relevant policies and procedures are reviewed regularly and maintained including training updates with affected staff. May have input into policies as required. Individual functional leadership is responsible for development and writing of the policies.* Interact with Corporate Compliance on issues related to adherence to corporate standards and identified deficiencies, working with executive leadership to create and implement new processes and corrective actions.* Maintains regular reporting to Corporate Compliance to ensure corporate standards are met and mentoring occurs.* Responds to various enquiries and work requests associated with compliance issues.

Relationship Building:

* Accept positive and negative constructive feedback.* Demonstrate a supportive/positive attitude toward the hospital and fellow employees.* Demonstrate a teaching and consultative approach to the quality sciences.* Provide and identify resources and shares as appropriate.

Results Oriented:

* Ability to demonstrate measurable results and achievements.* Effective in cost control and resource utilization.* Maintain and develop personal professional competency through the use of a learning plan.* Effective at taking action on analyzed data, improvement opportunities and then bringing the actions to closure in a timely manner.

Customer Mindedness:

* Maintain positive relationships with internal and external customers.* Proactive in meeting the customer's needs by using appropriate quality science tools.* Respond promptly to customer needs or requests.

Leadership and Role Modeling:

* Express self in an organized, comprehensive, articulate and concise manner.* Delegate appropriately to staff in keeping with job descriptions, license requirements and standards of practice.* Assume a leadership role in the maintenance of the patient-focused care delivery system.* Ensure direct reports comply with job duties and requests in the organization.* Active in strategic planning, balanced scorecard and business planning efforts; and, rolls out to all services and departments that are direct reports.

Critical Thinking Application:

* Demonstrate consistent approach of balancing ownership and accountability to all participants.* Is statistically minded using inductive and deductive reasoning when problem solving.* Use resources appropriately to augment personal skills and knowledge to help achieve world-class quality outcomes for the hospital.

Project Management:

* Establish reasonable deadlines with an emphasis on a quick turnaround of two days for most quality efforts.* Provide management updates and assures project recognition is incorporated into all systems.* Meet deadlines for regulatory compliance and project completion. .

Regulatory Compliance:

* Maintain global oversight for coordinating compliance with TJC, Medicare, and State standards.* Facilitate the team that is in charge of ensuring regulatory readiness.* Assist with mock survey processes.* Work in tandem with the Safety Officer, Patient Safety Officer and Risk Manager to achieve full compliance with regulations.

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Keywords: Surgery Partners, Bakersfield , Director of Quality, Executive , Bakersfield, California

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