About this opportunity
Mountains Community Healthcare lists this Quality Director opportunity in lake arrowhead, California. Review the employer’s description below for duties, qualifications and application requirements.
Job description
SUMMARY
The Quality and Regulatory Compliance Director is responsible for the program development, implementation, and management of Quality improvement initiatives, risk management, corporate compliance, patient safety and patient experience activities throughout the hospital district. This Director effectively engages everyone in the organization to improve quality performance and communicates all quality activities to the medical staff, Board of Directors, administration and staff. This position is responsible for gathering and reporting quality data to outside quality improvement organizations in an accurate and timely manner. This Director coordinates, investigates, and responds to customer complaints and patient-related issues. This Director is also responsible for maintaining regulatory compliance of the organization and has a working knowledge of State and Federal regulations.
QUALITY AND REGULATORY COMPLIANCE RESPONSIBILITIES:
**This is not an all-inclusive list and is subject to change, elimination and addition of responsibilities in response to the ever changing climate of hospital regulation and quality.**
Preparation for and coordination of regulatory surveys
Regulatory survey response and compliance
Regulatory Self-reporting activities and follow-up
Quality Review Report review and follow-up
Failure Mode and Effect Analysis and Root Cause Analysis investigation and reports
Complaints: investigation and follow-up
Patient satisfaction surveys
Beta HEART program
Service Excellence Initiative oversight
Committees
Continuous Quality Improvement Program
Nurse Advisory and Regulatory Compliance Committee
Board of Directors Quality Committee
Peer Review chart prep and committee participation
Medication Error Reduction Program
Falls Committee
Wound Care Committee
Fire, Life, Safety/Emergency Operations Committee
Team Walk Rounds
Beta HEART Steering Committee
Service Excellence Council
CHA Certification and Licensing Committee
Medical Executive Committee
Infection Control Committee
Medi-Tech Clinical Systems Optimization Committee
Patient & Family Advisory Council
Corporate Compliance Committee
Data Collection and Reporting
Emergency Department Transfer Communication
Departmental Quality Dashboards
Patient Experience Surveys
MBQIP, NHSN, HQR (IQR, OQR), eCQMs, TJC DDSP
Dexur – IQR, OQR, SIERA files
HQIP – IQR, OQR
Survey Solutions
Ongoing Professional Practice Evaluation
Additionally
Department Manager meeting
New Employee Orientation – Quality, Service Excellence
Policy review and development
FLEX and SHIP Grant management
Bachelors’ degree required
Experience required
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION/EXPERIENCE
Bachelor's degree required
Experience Required
CERTIFICATES, LICENSES, REGISTRATIONS
Current RN License in California or ability to obtain CA license within 30 days of hiring is required
CPHQ certification preferred
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Worksite address
lake arrowhead, CA, 92352, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.