DIRECTOR OF QUALITY
Company: Air Combat Effectiveness Consulting Group, LLC
Posted on: September 18, 2022
Posted Date 2 years ago (11/24/2020 5:35 PM) Requisition ID
req9404 Facility Corporate Office # of Openings 1 Shift Days
Category Quality Management Position Type Regular Full-Time
Overview Primary Function The Director of Quality collaborates with
the Patient Experience Officer, each hospital leadership team and
staff to provide strategic improvement plans with a focus on
improved operations for ancillary areas. The Director of Quality is
responsible for providing expertise, leadership, modeling and
support in accordance with AHMC initiatives designed to improve
performance and achieve sustainable high quality outcomes and
results for ancillary areas. Responsibilities Nature and Scope
- Leads and directs all quality management activities including
patient care, The Joint Commission compliance, risk management,
safety, performance improvement and infection control.
- Must be current with all pay for performance programs,
government regulations, and key health care systems initiatives
regarding medical records documentation and plan of care.
- Performs medical record abstraction for the purpose of quality
improvement or reporting.
- Reviews and analyzes healthcare data and records, validating
accuracy and quality documentation to ensure compliance with
- In collaboration with Patient Experience Officers, Quality
Improvement Directors, and hospital leadership, creates and
promotes a culture of quality through a cohesive, collaborative,
and effective interdisciplinary leadership team to support
strategies and quality initiatives.
- Provides strategic and technical direction in the assessment
and development of opportunities related to data management
strategies, data storage, information management tools and includes
the development and monitoring of reports.
- Develops strategic plans and policies for improved quality
throughout AHMC. Works with top management to ensure compliance
with regulatory agencies.
- Directs and supports Quality Improvement programs for hospital
operations. Assures quality imperatives are met including the
development of policy and criteria and determines thresholds for
action plans when needed.
- Directs processes and overall quality improvement activities
that results in improvement in patient care and operations that are
- Provides education to leadership team and healthcare providers
on best practice patient care as well as documentation,
interpretation and compliance.
- Collaborates with quality initiative teams and process
innovation to improve care delivery and documentation.
- Manages and coordinates closely with the committee
chairpersons, Quality, and Patient Experience Officers to assure
peer review activities are timely and demonstrate ongoing
monitoring of important measures.
- Communicates routinely with the Chairman of the Board and
partners with the Quality and Patient Experience Officers and
requests assistance as appropriate.
- Develops and facilitates Performance Improvement teams in
designated areas to accomplish measurable goals in a timely manner
and which demonstrates sustained improvement, enhanced work
environment and increased productivity.
- Assumes a sponsorship role for Quality Improvement initiatives
in partnership with CEO's, CMO's, and CNO's, aligned with
standardized best practice measured by key performance
- Leads a visible and transparent project prioritization process
to align resources with initiatives and to ensure interdisciplinary
efforts are in support of organizational strategic priorities.
- Consistently communicates and collaborates with Patient
Experience Officers and Quality Improvement Directors across all
AHMC's hospitals and affiliated offices to ensure established goals
- Presents Quality Improvement standards and practices to the
Executive Team, Compliance Officer and others in a timely basis to
ensure continuous compliance and vigilance with quality
improvement, patient care and patient safety.
- Monitors and presents results of improvement efforts and
ongoing measures of clinical processes to the leadership team.
- Consistently strives to understand, anticipate and meet the
needs, expectations and satisfaction levels of all customers.
Errors, inefficiencies and inaccuracies are addressed and resolved
- Develops and implements long-term strategies for the
organization leveraging emerging healthcare, digital and business
trends and collaborates with administrative and clinical leaders to
deliver strategic business value.
- Possesses and maintains a working knowledge of The Joint
Commission standards, state of California laws and statutes (e.g.
Title XXII), Medical Staff bylaws, policies and procedures and
- Organizes compiles, and reports data for designated areas to
identify trends, establish priorities, and recommend improvement
- Performs comprehensive retrospective reviews (concurrent, if
applicable) in a timely manner utilizing criteria developed and
approved by the medical staff and hospital where applicable.
- Manages and provides leadership of important measures and where
opportunities are identified, result are sustained, and ensures
continued measureable improvement.
- Develops and maintains effective screening for clinically and
financially appropriate admissions, transfers and discharges.
- Participates in community education projects.
- Abides by the hospital's Code of Conduct, Policy and procedures
and HIPAA compliance.
- Performs other duties as assigned. Qualifications
Qualifications Minimum of 5 years of Utilization Management plus 3
years' experience in a management position required. Experience in
leading multidisciplinary teams for ancillary areas. In depth
knowledge of all components of Performance Improvement including:
Patient Safety, Medical Staff, The Joint Commission, Title XXII,
monitoring and evaluation methodologies and statistical data
management. Working knowledge of contracts and payor/patient mixes.
Knowledge of HIPAA and privacy regulations. Possesses excellent
communication and negotiation skills. Ability to communicate
effectively with internal and external resources. Strong
organizational skills with the ability to multi-task and prioritize
workload. Previous experience in a hospital environment as a
Director of Quality or as highest-ranking leader for Quality
Improvement. Significant experience in a health care setting is
mandatory. Education: Requires a bachelor's degree in Nursing or
Business Administration or Master's degree preferred. BSN
preferred. RN in state of California preferred. Certified
Professional in Healthcare Quality (CPHQ) preferred.
- Outstanding communication skills, both written and verbal.
- Conducting root cause analysis.
- Budget preparation and monitoring.
- Planning and organizing.
- Management and leadership. Demonstrated ability to:
- Relate to all levels of the user community.
- Be a team player who is knowledgeable, motivates and educates
other team members.
- Plan, implement and support systems in a complex health care
- Set and manage priorities.
- Comprehend complex, technical subjects and the ability to
articulate to all members of the team.
- Translate technical language to lay audiences.
- Link and apply complex technologies to business strategies.
Hospital Description Dimensions AHMC consists of a corporate office
and seven acute care hospitals, and one skilled nursing facility,
AHMC Anaheim Regional Medical Center 228 beds, Garfield Medical
Center with 211 beds, Greater El Monte Community Hospital with 115
beds, Monterey Park Hospital with 102 beds, San Gabriel Valley
Medical Center with 273 beds, Seton Medical Center with 357 beds,
Seton Medical Center Coastside a 116-bed skilled nursing facility,
and Whittier Hospital Medical Center with 172 beds. The facilities
are Medicare and MediCal certified and accredited by the Joint
Commission on Accreditation of Healthcare Organizations. The
hospitals provide healthcare services reimbursed by Medicare,
MediCal, traditional insurance plans, PPO, HMO and under capitated
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Keywords: Air Combat Effectiveness Consulting Group, LLC, Alhambra , DIRECTOR OF QUALITY, Executive , Alhambra, California
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