Director of Quality, Patient Safety, Accreditation and Licensing
Company: Martin Luther King, Jr. Community Hospital
Posted on: February 12, 2024
The Director of Quality and Patient Safety is a key member of the
management team. The Director is integrally involved in ensuring
patient safety and clinical compliance throughout the organization
according to the local, state, and federal standards. The Director
is also responsible for leading performance improvement initiatives
based on areas of priority and indentified need. The Director works
closely with the hospital and medical staff to achieve departmental
and organizational goals.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Manage and direct daily operations and functions of the Office of
Quality and Performance Improvements including employee selection,
supervision, counseling, and recognition.
- Oversee and participate in the direction, implementation and
evaluation of the Quality and Performance Improvement Plan and
Patient Safety Plan
- Develop and implement quality and patient safety programs to
comply with regulatory agencies and accreditation bodies.
- Develop, implement and monitor programs to achieve performance
improvement goals and patient safety initiatives defined for the
organization. Design and implement a data collection /observation
team that will maintain a level of awareness of potential areas of
vulnerability and evaluation of internal practices. Direct the data
collection necessary to produce reports for administration, medical
staff, and the Board of Directors that demonstrate effectiveness of
the performance improvement and patient safety activities. Provide
periodic progress reports to Administration and Board of Directors
which are comprehensive and accurate.
- Oversee the process to obtain clinical data for
routing/reporting to external sources, including but not limited
to, CA Department of Public Safety, CMS/ Joint Commission,
CDC/NHSU, CALHIIN, CalNOC, and Leapfrog Group. Oversee public
reporting of adverse events to appropriate accrediting and
- Work collaboratively with the executive and clinical operations
team to develop and maintain the hospital's culture of quality and
patient safety. Bring issues regarding quality to immediate
attention of hospital administration and leadership. Take
appropriate action, including staff and employee education, to
correct or improve outcomes.
- Provide leadership and support for all accreditation and any
disease specific certifications/activities to ensure compliance
with all accreditation standards. This includes required
accreditation activities such as the Periodic Performance Review.
Participate and represent accreditation issues as various hospital
committee(s) as assigned. Lead and/or assist with the preparation
and acquisition status issued including required hospital
correspondence, documentation, participation, and compliance.
Prepare for the receipt of hospital designations that promote
quality. Research appropriate agencies and national associations
for best practice as it relates to accreditation and regulatory
- Serve as a clinical educator for staff orientation. Assure all
new staff members are oriented to the quality and patient safety
during initial orientation. Provide ongoing communication of
regulatory standards to all levels of constituents of the hospital
with emphasis on quality abd patient safety while driving for
- Develop and recommend hospital and medical staff performance
improvement activities consistent with strategic objectives and
plan. Collaborate with the Medical Staff office to provide
physician ongoing professional performance evaluations.
- Develop and maintain strong collaborative working relationships
with the hospital and medical staff leadership. Act as a consultant
to all departments on performance improvement activities.
- Review evidence based order sets and guidance for clinical
practice, as needed, and in collaboration with medical and nursing
- Facilitate/participate in RCAs within the organization and
includes all appropriate individuals.
- Helps establish a "Just Culture" of accountability in the
organization through relevant Polices and Procedures and training.
Review pertinent policies and procedures, forms, bylaws and
contracts for adherence to current standards, laws and regulations.
Assist in the development of hospital and departmental policies and
procedures. Assist in the evaluation and application of policy and
process into and across function's in an efficient and integrated
way that emphasizes quality and patient safety.
- Develop and coordinate a program that ensures frontline staff
are informed, participating and engaged in hospital process that
impact quality and patient safety, and assures a continual state of
- Undergraduate nursing degree required. Master's or doctoral
- Progressive leadership experience with minimum of three years
in Quality, patient Safety and Accredation/Licensing
- Current California Registered Nurse State licensure
- Certified Professional in Healthcare Quality (CPHQ)
C. Special Skills/Knowledge
- Excellent communication skills and evidence of collaborative
- History of successful clinical and performance outcomes.
Expertise in healthcare delivery systems and performance
- Knowledge of accreditation and federal and state regulatory
standards is required. Proficient in email, Excel and internet
- Knowledge of various quality improvement methodologies
including LEAN and Six Sigma.
- Ability to collaborate in a team environment and produce
positive outcomes by motivating others.
Keywords: Martin Luther King, Jr. Community Hospital, Alhambra , Director of Quality, Patient Safety, Accreditation and Licensing, Executive , Alhambra, California
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