Director, Quality, Risk Prevention and Accreditation

Legal & Compliance
Southern California Region
44959 Requisition #
Adventist Health is more than an award-winning health system. We provide whole-person care to our communities and champion the greater good - from the operating room to the boardroom, we are driven by our unique passion to live God's love through health, wholeness and hope. From Oregon to Oahu, we have a calling to always do more. Now is your chance to apply your passion to our mission.
We're looking for someone to join our team as a Director, Quality, Risk Prevention and Accreditation
Maintains responsibility for Quality Management and Risk Prevention functions. Provides overall direction, development, implementation and integration of the Quality Management program which includes compliance with all the Joint Commission, Federal, State and local reporting requirements. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment. Leads, develops and deploys a comprehensive, highly reliable program across the continuum of care and implements the organization's vision of excellence in clinical and quality outcomes and patient safety. Establishes a structure that supports the organization through analytics, analysis and High Reliability Organization (HRO) safety initiatives such as Culture of Safety, Just Culture and others included in strategic directives. Works closely with the ministry leaders of quality, physician services, nursing leadership and homecare to champion communication, transparency, teamwork and a culture of safety. Supervises Infection Prevention program that is responsible for surveillance, analysis, interpretation and reporting of Hospital Acquired Infections (HAI) and infection prevention education.

Essential Functions:

Champions clinical quality performance and patient safety, to meet established patient safety, quality and compliance goals. Directs the development of programs and processes related to Quality Management. Provides education to all quality leadership and executives. Facilitates organization wide transition to a High Reliability Organization through development of policies, standards, indicators, implementation and evaluation techniques. Develops policies and procedures, monitors performance, develops and reviews metrics, assesses and prioritizes risk, and reports results to leadership. Serves as a resource to quality teams, medical staff and executives.

Develops and maintains the quality and patient safety plans for the organization. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives. Supports organization in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees.

Collaborates with analytics teams to develop and maintain quality metrics that meet required reporting such as Electronic Clinical Quality Measures (eCQM) and more. Works with analytic team and our Electronic Health Record (EHR) vendor to apply meaningful analysis and process improvement. Knowledge leader for Value-Based Purchasing (VBP), Healthcare Associated Infection (HAI), readmissions, mortality and more for any clinical performance programs such as government or commercial pay for performance. Supports quality metrics for contracted services as needed.

Evaluates various attributes of health care, such as safety, cost, place, treatment, and benefits as compared with standard results, for the purpose of making recommendations for improvement using standardized Performance Improvement (Pl) and Root Cause Analysis (RCA) techniques. Facilitates development of proactive programs to minimize risk. Initiates and monitors efforts to preserve evidence.

Educates staff regarding information necessary to ensure Quality, Safety, Licensure & Accreditation. Develops and implements an ongoing preparedness for regulatory agencies' plan.

Performs other job-related duties as assigned.

You'll be successful with the following qualifications:


Bachelor's degree in a healthcare-related field, preferably Nursing, or equivalent combination of education/related experience: Required

Master's degree: Preferred

Work Experience:

Seven years' clinical experience in acute care setting, or equivalent combinations of education/related experience: Preferred

Seven years' healthcare quality leadership, project management/lean or sigma training and experience building or leading a High Reliability Organization (HRO): Preferred

Five years' leadership experience: Preferred

Required License/Certifications:

Registered Nurse (RN) license in state of practice: Required 

Certified Professional in Healthcare Quality (CPHQ): Required
Required Skills

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