Director Quality and Patient Safety - CommonSpirit Health

Founded in 1955 Dignity Health – Northridge Hospital Medical Center is a 394-bed acute care nonprofit community hospital located in Northridge California. The hospital offers a full complement of award winning services including the Leavey Cancer Center a cardiovascular center stroke center the Center for Assault Treatment Services a pediatric medical center and the only pediatric trauma center in the San Fernando Valley. As a leading provider of compassionate high-quality and affordable patient-centered care we share a rich legacy with Dignity Health one of the nation’s five largest health care systems. We are part of a 21-state network of nearly 9000 physicians 62000 employees and more than 400 care centers. Visit dignityhealth.org/northridgehospital for more information.

If you are committed to social justice, health equity, and prepared to deliver care in new, innovative ways, you belong with us.

We offer the following benefits to support you and your family:

• Relocation Assistance.
• Annual Incentive (Bonus) Program.
• Matching Retirement Program.
• Pension fully funded by the Hospital.
• Tuition Assistance for career growth and development.
• Health/Dental/Vision Insurance.
• Free Membership to our Care@Work program supporting child care, pet care, and adult dependent needs.
• Employee Assistance Program (EAP) for you and your family.
• Flexible spending accounts.
• Voluntary Protection: Group Accident, Critical Illness, and Identity Theft.
• Wellness Program.
• Paid Time Off (PTO).

Position Summary:

As our Director of Quality and Patient Safety for Northridge Hospital, you will establish performance improvement goals annually with relevant stakeholders, and ensures the Performance Improvement Plan and the hospital-focused projects for the year are implemented and their effectiveness is evaluated.

You will develops and implement processes and formats which support data collection, aggregation, analysis, and action planning, and assure data is managed appropriately and disseminated to leadership staff. You will provide leadership in developing quality improvement and patient safety training programs and coach organizational clinical/service lines and operational/support departments in quality improvement principles.

You will also implement and oversee the organization-wide patient safety program and manage the reporting, data analysis and evaluation as outlined in the Patient Safety Plan.  In addition, you will also oversee the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability).

You will participate in system office initiatives and programs to mitigate risks in the facility which have been identified at other Dignity Health hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care.
You will also direct accreditation and regulatory survey readiness, lead mock survey tracers to assess survey readiness, provide education to staff and providers on regulatory compliance, and organize required staff to develop responses to survey deficiencies and submit responses to the appropriate accreditation or regulatory agency.

Required Education and Experience: 

• Bachelor's 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 a healthcare setting, two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
• Minimum of two (2) years of clinical, patient care experience or equivalent.

Required Licensure:

• Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.
• 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.

Required Special Skills:

• 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
  
• Experience with patient compliant/grievance investigations and prompt resolution
  
• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks
  
• Familiar with all legal documents related to hospital liability, including management of subpoenas, Summaries and Complaints and other related activities
  
• Knowledge of processes, tools and techniques for assessing and controlling an organization's exposure to risks of various kinds; ability to apply this knowledge appropriately to diverse situations.
  
• Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/reward

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