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Director of Quality, Patient Safety, Accreditation and Licensing

Company: Martin Luther King, Jr. Community Hospital
Location: Alhambra
Posted on: February 12, 2024

Job Description:


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.


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 governmental agencies.
  • 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 readiness strategies.
  • 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 sustainability.
  • 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 staff.
  • 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 readiness.


    A. Education
    • Undergraduate nursing degree required. Master's or doctoral degree preferred.
      B. Qualifications/Experience
      • Progressive leadership experience with minimum of three years in Quality, patient Safety and Accredation/Licensing
      • Current California Registered Nurse State licensure preferred.
      • Certified Professional in Healthcare Quality (CPHQ) preferred
        C. Special Skills/Knowledge
        • Excellent communication skills and evidence of collaborative practice.
        • History of successful clinical and performance outcomes. Expertise in healthcare delivery systems and performance improvement.
        • Knowledge of accreditation and federal and state regulatory standards is required. Proficient in email, Excel and internet programs.
        • 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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