Director Quality Patient Safety

Overview
Dominican Hospital (a member of Dignity Health) is a 222-bed facility that offers a wide range of services to residents of California's Central Coast. With 24/7 emergency care comprehensive care in cardiac orthopedics oncology women's and children's services we continue to lead the region in medical innovation and excellence in healthcare. Comprehensive CareDominican offers emergency services and is a Certified Stroke Center and Chest Pain Center. Dominican's services include the only comprehensive Cancer Center in Santa Cruz County a Total Joint Replacement program and advanced neurological and endoscopic services. Dominican regularly receives 'A' grades for hospital safety from Leapfrog Group and has received national recognition for superior Patient Safety cardiac care and stroke treatment from Healthgrades a leading provider of comprehensive information about physicians and hospitals.As Santa Cruz County's heart attack (STEMI) receiving center Dominican Hospital provides cutting edge cardiac care. The hospital's heart attack treatment times consistently beat the national average and the hospital offers two cardiac catheterization labs available 24 hours a day 7 days a week. Groundbreaking cardiac procedures at Dominican include the Transcatheter Aortic Valve Replacement (TAVR) procedure which allows for heart valve replacement without opening a patient's chest.Dominican Hospital has forged significant partnerships with area hospitals to bring exceptional care to Santa Cruz County. The hospital offers a level III Neonatal Intensive Care Unit (NICU) through a partnership with Lucile Packard Children's Hospital Stanford. Neurosurgery at Dominican is also offered through a partnership with Stanford Health Care.
Responsibilities

• Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement and Patient Safety plans and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection aggregation analysis and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and Patient Safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles.
• Oversees the events reporting process root cause analyses investigations and requests from the claims team (including management of subpoenas Summons and Complaints and coordination of legal documents related to hospital liability). Participates in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals resulting in reduced costs adverse patient outcomes and ultimately safer patient practices and care.
• Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes including the organization's peer review program and ongoing and focused practitioner evaluation.
• Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency.

Qualifications
Education and Experience:

• Bachelors degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.
• Minimum of five (5) years of progressive management responsibility in an acute care setting two (2) of which is related to managing an organization's Quality Improvement Program. Minimum of two (2) years of clinical patient care experience or equivalent. Experience developing and implementing clinical service and operational process improvement initiatives both small and large scale. Knowledge and expertise in specific performance improvement/CQI methodologies (e.g. Six Sigma LEAN). Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state federal local regulations; Joint Commission etc.).

Licensure:

• Certified Professional in Healthcare Quality (CPHQ) or Healthcare Quality and Management Certification (HCQM) or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.