Director, Quality - Los Banos, United States - Sutter Health

Sutter Health
Sutter Health
Verified Company
Los Banos, United States

2 weeks ago

Mark Lane

Posted by:

Mark Lane

beBee recruiter
Description

Organization

:

MHLB-Memorial Hospital Los Banos


Position Overview

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Established to serve the needs of the growing Westside community in Merced County, Memorial Hospital Los Banos (MHLB) opened its doors on Sept.

5, 1967.

Today, MHLB is accredited by the Joint Commission on Accreditation of Healthcare Organizations and operates as a non-profit, general care medical center with 26 active physicians on staff.


A mission answers the question "Why do we exist?" Our mission statement: Memorial Hospital Los Banos provides high quality compassionate care and exercises prudent fiscal responsibility.


Works as part of the operations leadership team to accelerate the measurable and continual progress in meeting the organization's quality objectives.


Has significant responsibility for working with the organization to pursue operational improvements and efficiencies, supporting the development and implementation of clinical assessment/process improvement and redesign.

Pursues opportunities for work that adds value and eliminates waste and redundancy for the organization to help achieve and retain optimal quality outcomes.


EDUCATION

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  • Bachelor's: Management, public health, nursing, business administration, organizational leadership or related field.

CERTIFICATION & LICENSURE

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  • RN-Registered Nurse of California
  • OR MD-Medical Doctor
  • OR PharmD-Pharmacist
  • OR PA-Physician Assistant
  • OR NP-Nurse Practitioner

TYPICAL EXPERIENCE

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  • 12 years recent relevant experience.

JOB ACCOUNTABILITIES

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Quality Improvement Functions

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Develops, implements, and provides coordination of affiliate's Continuous Quality Improvement (CQI) Program. Utilizes observational skills and other appropriate data sources to gather information on clinical and operational processes to improve the organization's processes, recommend solutions, and implement action plans

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Integrates CQI with the medical staff structure and activities and implements coordination of the performance improvement program across all departments and including the Board of Directors

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Provides education and direction to hospital management and medical staff leaders in CQI concepts and techniques and works to continuously integrate quality improvement functions across departments and with medical staff and between the medical staff and the patient service departments

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Provides independent project leadership on assigned projects, including focus on coordination of initiatives related to process improvement and redesign

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Deconstructs processes, assesses operations, and implements recommendations for developing best practices for implementation and develops baseline and ongoing measurements to track improvement

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Patient Safety Functions

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Plans, organizes and coordinates all aspects of the Patient Safety program within the facility. Is responsible for developing and maintaining a comprehensive patient safety program including identification, evaluation and coordination of corrective action implementation related to identified safety issues in conjunction with the risk management leadership

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Maintains knowledge of regulatory/accrediting agencies, statutes and reporting requirements

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Collaborates with Risk Management leadership in identification and reporting of real and potential patient safety issues

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Maintains direct responsibility to make timely reports to leadership, medical staff, administration, hospital departments and committees, as appropriate

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Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce harm/potential harm associated with the provision of patient care. Acts as the facility Patient Safety Officer

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Is responsible for the facilitation and conduct of the harm measurement system for safety events. Manages the recording and reporting of harm events utilizing the proscribed tools and methods

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Coordinates with the risk management leadership on risk management and patient safety activities which include but may not be limited to coordinating those systems necessary for identification, evaluation, monitoring, reduction and/or elimination of patient harm, including the conduct of root cause, apparent cause, and common cause analyses based on patient harm/patient safety/risk management issues/events

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Provides counseling and education to the administrative and management staff, clinical personnel, and medical staff members related to the patient safety day-to-day operations

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Manages analysis and reporting of patient safety data to the organization, leadership, and Sutter Health

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Accreditations/Regulatory Functions

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- ** Oversees organizational compliance with regulations governing rules of accrediting bodies as it relates to acute care hospitals & related services. Develops and implements strategies that support continuous survey readiness. Establishes, and defines progr
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