Director Quality

Dignity Health Mercy San Juan Medical Center is a 370-bed not-for-profit Level 2 Trauma Center located in Carmichael California serving the areas of north Sacramento County and south Placer County for more than 50 years. It is one of the area’s largest and most comprehensive medical centers. Dedicated to the community’s well-being our staff and volunteers provide excellence in care for our patients each year. Mercy San Juan Medical Center has received recognition for being a Comprehensive Stroke Center and Center of Excellence for Bariatric Surgery along with Certificates of Excellence in Perinatal Care Hip- and Knee- Replacement.  

One Community. One Mission. One California

This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and identifies opportunities for improved patient care, incorporate evidence-based practices, and improved patient outcomes. 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.

• Establishes performance improvement goals annually with relevant stakeholders, ensures that the PI plan and the hospital-focused projects for the year are implemented and effectiveness evaluated annually. Facilitates a multidisciplinary approach to performance improvement and fosters participation in all performance improvement initiatives to share and learn best practices. Develops and implements processes and formats that 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 training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles.
• 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.
• Ensures compliance and provides leadership and oversight for accreditation, licensure and regulatory survey readiness. This includes mock survey tracers to assess survey readiness, education to staff and providers on regulatory compliance and identification for areas of opportunities and the corresponding actions for compliance at the facility level. Organizes required staff to develop responses to survey deficiencies and oversees response submissions to the appropriate accreditation or regulatory agency.
• Has overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.

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

• Health/Dental/Vision Insurance
• Flexible spending accounts
• Voluntary Protection: Group Accident Critical Illness and Identity Theft
• Adoption Assistance
• Free Premium Membership to Care.com with preloaded credits for children and/or dependent adults
• Employee Assistance Program (EAP) for you and your family
• Paid Time Off (PTO)
• Tuition Assistance for career growth and development
• Retirement Programs
• Wellness Programs

Education and Experience:

• Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of a degree.
  Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
  Minimum of two (2) years of clinical, patient care experience or equivalent.

Required licensure and certification: 

• Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.
• 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.

Required Minimum Knowledge, Skills, Abilities and Training:

• Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
• Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities
• 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.).
• Experience with the event reporting process, root cause analyses, and event investigation/review
• Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/reward contributions; define clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary.
• Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations.
• Ability to identify opportunities and take action to build strategic relationships between one’s area and other areas, teams, department, units or organizations to help achieve business goals
• Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization.