Develops, implements and directs the comprehensive quality programs for KFH/Health Plan Service Area. Director may have oversight over one or more of the following: quality assessment and improvement, patient safety, risk management, professional staff services or accreditation, regulatory and licensing. Works with the medical center leadership team to ensure that the programs effectively measures, assesses and continuously improves the quality of care and service provided.
Essential Responsibilities:Directs the Service Area's quality program in order to meet the organizational goals.Facilitates departmental activities so as to meet the requirements of customers and regulatory and accrediting agencies to include peer and departmental reviewsMitigates medical/legal liability through development of a program which links risk management activities with those of continuous performance improvement.Serves as a critical link in the identification and resolution of issues which affect the organizational image.Works closely with designated Chiefs of Service and Department Administrators to address patient care issues with a goal toward resolution while maintaining confidentiality.Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals.Works closely with the medical, nursing, and support staff to enhance compliance and patient safety.Provides education and technical support to the Service Area in developing, implementing and maintaining quality improvement activities.Facilitates performance improvement throughout the continuum of care to improve the care, treatment and services provided.Manages the creation and maintenance of provider-specific quality profiles to be used for credentialing.Develops and maintains relationships and effective communication with all levels of Service Area. Collaborates with various stakeholders on projects, initiatives and facilitates spread of best practices. Prepares reports as required to Quality Committee from KFH to the Kaiser Permanente Board of Directors.Contributes to the management of the accreditation, regulation, and licensing activities to include communicating the programs/processes to providers and medical staff, preparing of surveys and inspections, and completing assessments, response plans and measures of success.Responsible for the completion of annual evaluations and revisions to the Quality Program.Directs human resources management processes: hires, fires, promotes, demotes, manages and evaluates staff performance and development. Develops, monitors, and controls department budgets.Makes recommendations regarding the need for staff, space and other resources.May be expected to perform other duties as assigned.Ensures annual evaluation of Health Plan facility contracts for quality assurance.
Works collaboratively with Regional and Service area departments to promote and implement quality patient care through appropriate measurements of care.Patient Safety:Accountable to promote an organizational culture of safety and ensure appropriate patient safety standards and guidelines are implemented consistently in the delivery of health care to our patients, including but not limited to: TJC, National Quality Forum, and Leapfrog. See Patient Safety Management Accountabilities Addendum for job specific accountabilities. (My HR Forms).
Experience Minimum five (5) years of experience in Quality Improvement in a health care setting. Minimum three (3) years management experience.
License, Certification, Registration California RN license required
Additional Requirements: Experience designing, developing, and implementing physician peer review. Demonstrated knowledge of governmental accreditation and other regulatory standards, requirements, and guidelines related to quality performance. Strong working knowledge of ongoing monitoring processes (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; performance improvement principles, tools, and techniques. Effective communication, negotiation and leadership skills. Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications: Clinical nursing experience preferred.
Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred.
Bachelor's degree in Nursing or Health Care related field or business administration preferred Master's degree preferred in Nursing or Health Care related field or Business Administration.
Additional Preferred Qualifications:
5 years direct leadership experience
Knowledge of CMS Star rating measures, Leapfrog Hospital Safety Score, and TJC/CDPH Quality requirements