Director of Quality and Patient Safety - CommonSpirit Health

Nestled in the heart of East Sacramento Dignity Health Mercy General Hospital is a 313 bed acute care facility that provides a wide range of services with special advocacy for the poor and underserved. Mercy General is home to the nationally ranked Alex G. Spanos Heart & Vascular Institute. Key achievements and recognitions include: from the Joint Commission; Advanced Joint Replacement Spine Center of Excellence Primary Stroke Center Ventricular Assist Device and Chest Pain Certification. Other accolades include CMS 5 stars Practice Green Health 2021 Leapfrog Hospital Safety Grade A Level 4 Epilepsy Center and Opioid Stewardship Honor Roll. Mercy General Hospital is proud to foster inclusion and diversity as part of our mission vision and values.

This position is responsible for the design, coordination, implementation and management of the Performance  Improvement (PI) plan and identifies opportunities for improved patient care, incorporate evidence-based practices, and  improved patient outcomes. Provides leadership in defining, implementing and integrating quality, safety, service and  efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and  strategic direction.

• Knowledge of quality management methods, tools, and  techniques and ability to create and support an environment  that meets the quality goals of the organization. 
• Knowledge of federal, state and local healthcare related laws  and regulations; ability to comply with these in healthcare  practices and activities 
• Experience developing and implementing clinical, service and  operational process improvement initiatives, both small and  large scale.  
• Knowledge and expertise in specific performance  improvement/CQI methodologies (e.g. Six Sigma, LEAN). ∙ Current knowledge of accreditation and regulatory  requirements for acute and ambulatory care services (e.g.  state, federal, local regulations; Joint Commission, etc.). ∙
• Experience with the event reporting process, root cause  analyses, and event investigation/review
• Establishes performance improvement goals annually with relevant stakeholders, ensures that the PI plan and the  hospital-focused projects for the year are implemented and effectiveness evaluated annually
• Develops and implements processes and formats that support data  collection, aggregation, analysis, and action planning

Education and Experience:

• Bachelors degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.
• Minimum of five (5) years of progressive management responsibility in an acute care setting two (2) of which is related to managing an organization’s Quality Improvement Program
• Minimum of two (2) years of clinical patient care experience or equivalent.

Licensure:

• Certified Professional in Healthcare Quality (CPHQ) or Healthcare Quality and Management Certification (HCQM) or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required
• Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.