Exciting INTERIM job! Receive per diem rate plus typical out-of-pocket expenses such as: Airfare to/from hospital at start & end of assignment, plus trip home every other weekend, hotel/housing, and rental car & gas.
Job Title: Interim Quality and Accreditation, Regulation and Licensing Director DEPARTMENT: Quality SCHEDULE: Full time regular, 40 hrs/week, Day shift, Monday-Friday, 8:00am to 5:00pm EDUCATION/LICENSE/CERTIFICATION: Bachelor´s degree in health care administration, nursing, or public administration or related field required. Current California RN license (preferred) or other clinical licensure required. Masters Degree preferred. Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred. BLS, ACLS JOB SUMMARY: Directs the Medical Center quality program for hospital and ambulatory sites, which may include one or more of the following: quality assessment and improvement, accreditation and regulation licensing, and compliance. Partners with the medical center executive leadership team and departments to ensure that the program effectively measures, assesses and continuously improves the quality of care and service provided. Manages, facilitates and supports activities related to accreditation, regulation and licensing issues for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan. Translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses. Oversees Medical Staff Services including credentialing and privileging, CME, GME and Medical Library. QUALIFICATIONS: Experience designing, developing, implementing clinical improvement programs. Significant experience (usually 5 years) in Quality Improvement in a health care setting. Previous management experience required. Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement, such as The Joint Commission, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22, Cal-OSHA, HIPAA and Medi-Cal and Medicare regulations and standards. Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques. Effective communication, negotiation and leadership skills. Must be able to work in a Labor/Management Partnership environment.. PREFERRED QUALIFICATIONS: Previous management experience in nursing or other allied health professional experience preferred. SKILLS TESTING: RN Medication Math Testing DUTIES: Directs the medical centers quality management program, which supports the organizational goals and priorities, as well as the requirements of regulatory and accrediting agencies. Provides oversight for the medical center wide involvement in quality improvements, communicate opportunities, results and priorities. Works closely with designated Chiefs of Service and Department Managers 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. Provides education and technical support to the Medical Center in developing, implementing and maintaining quality improvement activities. Identifies and implements practices to improve quality and service. Collaborates with leadership, departments, clients, TPMG, and community in designing processes, tools and templates that continually improve the quality, efficiency, service and effectiveness of care and service. Consults and participates in performance improvement teams using a variety of methodologies. Partners with Risk Management to reduce medical/legal liability through development of a program which links risk management activities with those of continuous quality improvement. Serves as a critical link in the identification and resolution of issues, which affect the organizational image. Develops and maintains relationships and effective communication with all levels of medical center physicians and staff in order to facilitate problem identification and resolution. Oversees preparation of periodic reports to the KFH/HP Board of Directors and coordinates completion of the Quality annual evaluation, workplan and program description. Supports the peer review process and partners with medical staff to assure process completion. Oversees Medical Staff Services including credentialing, privileging, CME/GME and library responsibilities. Consults on data analysis techniques and evaluates trends to identify potential opportunities for improvement. Manages staff and makes recommendations regarding the need for staff, space and other resources. Manages and resolves human resources and labor relations issues specific to management responsibilities. Develops systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery. Analyzes, interprets and makes recommendations to meet federal, state and local requirements. Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective action to minimize negative impact and maximize learning. Relays internal/external communication of information related to accreditation, regulation and licensing. Prepares for surveys and inspections, including educational forums, coordinating mock surveys and assessments assists in developing response plans. Coordinates formal surveys for all regulatory and accrediting agencies. Interprets and assists in planning responses to new or changing regulations or standards. Collaborates with external regulators to develop standards, which promote high quality patient care and services. Serves as liaison to region, community groups, professional organizations, and licensing/regulatory agencies. Develops, implements, and meets the established financial goals. Monitors applicable budget, and identify and support solutions to reduce cost structure. In collaboration with TPMG, ensures development of a CME program which supports clinical quality goals, trended peer review findings and new technologies embraced by the INTC. Ensures the Medical Library resource supports the achievement of organizational goals through research and best practice identification. Strategically positions library services to support the organizations clinical quality goals and preventive health measures. Consistently supports compliance and the hospitals code of conduct by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and the hospitals policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the hospitals Service Quality Credo, hospitals mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.