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Director Quality and Patient Safety

St Bernardine Medical Center San Bernardino, California
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The posted compensation range of $59.53 - $86.32 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

Requisition ID 2023-335983 Employment Type Full Time Department Quality Management Hours/Pay Period 80 Shift Day Weekly Schedule Monday - Friday (8:00 AM - 5:00 PM) Remote No Category Risk and Compliance
Overview

Founded as a faith-based hospital in 1931 by the Sisters of Charity of the Incarnate Word, Dignity Health – St. Bernardine Medical Center is a  342-bed, acute care, nonprofit hospital located in San Bernardino, California.  The hospital offers a full complement of services, including the Inland Empire Heart and Vascular Institute, an award-winning orthopedics program, surgical weight loss, and is an official Neurovascular Stroke Center, as designated by ICEMA.  The hospital shares a legacy of humankindness with Dignity Health, one of the nation’s five largest health care systems.  Visit https://www.dignityhealth.org/socal/locations/stbernardinemedical for more information.

If you are committed to social justice, health equity, and prepared to deliver care in new, innovative ways, you belong with us.

We offer the following benefits to support you and your family:

  • Annual Incentive (Bonus) Program.
  • Matching Retirement Program.
  • Pension fully funded by the Hospital.
  • Tuition Assistance for career growth and development.
  • Health/Dental/Vision Insurance.
  • Free Membership to our Care@Work program supporting child care, pet care, and adult dependent needs.
  • Employee Assistance Program (EAP) for you and your family.
  • Flexible spending accounts.
  • Voluntary Protection: Group Accident, Critical Illness, and Identity Theft.
  • Wellness Program.
  • Paid Time Off (PTO).

Responsibilities
Position Summary:
Responsible for the design, coordination, implementation and management of the Organization’s Performance Improvement (PI) and Patient Safety plans. Identifies opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.
Principal Duties and Accountabilities:
  • 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: 
  • Bachelor's 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

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While you’re busy impacting the healthcare industry, we’ll take care of you with benefits that may include health/dental/vision, FSA, matching retirement plans, paid time off, tuition assistance, adoption assistance, and more!

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.

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Equal Opportunity

CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.

CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.