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DIRECTOR CLINICAL QUALITY RESOURCES

Company: Tri-City Medical Center
Location: Oceanside
Posted on: January 26, 2023

Job Description:

Job LocationsUS-CA-Oceanside
Overview
Tri-City Healthcare District has been serving the North County region for almost 60 years and remains committed to providing high quality healthcare and community services for every individual we encounter regardless of race, color, ethnicity, gender, sexual orientation, disability or socioeconomic status.
Our mission is to advance the health and wellness of the community we serve. In order to achieve our mission, we see, hear and listen to our front line healthcare workers, employees, medical staff and all community stakeholders in order to understand and meet our community's needs.
Position Summary:
The Director Clinical Quality Resources plans and directs the operational, budgetary and personnel activities for Quality, Patient Safety, Clinical Risk, Regulatory, Patient Experience and Infection Control/Prevention, to ensure alignment with organizational objectives.
Major Position Responsibilities:
The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.


  • Maintains a safe, clean working environment, including unit based safety and infection control requirements.
  • Responsible for the operational, budgetary and personnel activities for Quality, Patient Safety, Clinical Risk, Regulatory, Patient Experience and Infection Control/Prevention.
  • Provide oversight in preparation of regulatory reports for external agencies and presentations to the Board of Directors, Executive Council, Directors, and Medical Staff. - - -
  • Works with all levels in the organization to coordinate preparedness for hospital-wide surveys.
  • Directs and serves on committees to address issues relating to Quality, Patient Safety, Clinical Risk, Regulatory, Patient Experience and Infection Control/Prevention.
  • Works collaboratively with key healthcare professionals toward identification of opportunities for improvement, education, and development of appropriate action plans to ensure alignment with organizational objectives.
  • Exhibits the ability to make effective decisions based on verifiable and measurable data/criteria.
  • Develops and supervises all aspects of the Quality Assurance/Performance Improvement (QAPI) Program which meets the QAPI Committee recommendations and applicable accrediting organization guidelines. These guidelines may include but are not limited to those set by the Joint Commission or similar accrediting body, the Centers for Medicare and Medicaid Services, CFR's and the State of California. Reviews and updates program annually and as necessary.
  • Reviews, analyzes and monitors data, prepares reports on problems and trending and notes corrective action and improvement. Proactive in identification and resolution of improvement opportunities for Quality and Infection Control.
  • Coordinates, develops, retrieves and analyzes patient care outcomes and metrics by concurrent and retrospective processes and outcome monitoring for Medical Staff, Nursing and ancillary services.
  • Maintains oversight and direction of the Core Measure, Meaningful Use, LEAPFROG, HCAHPS, STAR Ratings, Evidence Based Practices, and Infection control processes and reporting. Remains current and advises the Chief Medical Officer and Chief Nursing Officer on all CMS Core Measures and other mandatory/voluntary reporting requirements.
  • Serves as a resource person to Nursing Services and Ancillary services for the development of patient interviews and monitoring activities.
  • Assumes primary responsibility for the Joint Commission certification or other regulatory and certifying body accreditation; remains current on all requirements of facility, states and the Joint Commission or other accrediting body organization requirements by attending relevant workshops/seminars and reviewing appropriate literature. Responsible for provision of necessary education to department leaders regarding all applicable regulatory requirements.
  • Serves as a contact point and leads/directs projects in conjunction with Regional and National initiatives as well as other quality metric projects as assigned.
  • Perform other duties as assigned. -

    Qualifications:

    • Minimum of five (5) years of clinical healthcare experience, required.
    • Prior management experience, required.
    • Experience in Medical Staff and Nursing Quality Management, systems performance improvement, and efficiency programs, required.
    • Possess knowledge of the business of health care along the continuum of care, clinical decision support data analysis/syntheses and quality improvement, regulatory and legislative issues, required.
    • Strong organizational, communication and interpersonal skills, both verbally and in writing required. Personal initiative and the ability to lead people, especially in relationship to the medical staff, along with exceptional and demonstrated relationship building and personal interaction skills with individuals in diverse educational and professional roles is required.
    • Demonstrated leadership ability working with all levels, required.
    • Demonstrated initiative and problem solving skills, using sound judgement, required.
    • Experience conducting/participating in Root Cause Analysis, required.
    • Experience with clinical data analysis and presentation, required.
    • Knowledge of regulatory quality indicators, required.
    • Knowledge of state and national regulations, standards, and operating definitions for evidence-based measures, required.
    • Must also have the ability to train and educate others based on relevant information gained through data analysis, required.
    • Understands concepts of reliability, outcomes management and fiscal integration, required.
    • Experience working with Quality Net, NHSN, CALNOC, NQDNI, HSAG, TJC, RL, Cerner and Quantros, preferred.
    • Able to multi-task in an organized efficient manner, required.
    • Self-directed learner and professional. - Enthusiastically seeks ways to improve patient care and motivates others to participate in improvement activities.
    • Computer operation skills, understanding of statistics, spreadsheets and database systems, required.

      Education:

      • Master's degree in nursing or health related field from an accredited university, required.

        Certification:

        • Certified Professional in Healthcare Quality (CPHQ), required.
        • Lean six sigma (or similar) certification, preferred.

          Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.
          *Salary/Hourly Wage range based on experience.
          To protect the health of patients and staff, and to comply with the new State of California mandates, all job offers are contingent on the successful engagement in the TCMC COVID-19 vaccination program (fully vaccinated with documented proof or approved exception/deferral.)
          TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.

Keywords: Tri-City Medical Center, Oceanside , DIRECTOR CLINICAL QUALITY RESOURCES, Executive , Oceanside, California

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