Director of Quality and Patient Safety - Sharp Grossmont Hospital - FT - Days

Sharp HealthCare•La Mesa, CA

3d•$74 - $116

About The Position

The Director of Quality and Patient Safety provides strategic oversight, direction, and integration of clinical quality and patient safety initiatives for the entity. Reporting to the Chief Medical Officer, this role is a key architect of the hospital's Quality Pillar, driving the strategic planning and execution necessary to achieve the SHC vision of top-decile clinical outcomes. The Director partners with executive leadership to foster a culture of safety, reduce clinical risk, and oversee complex data management systems. The Director is also responsible for the effectiveness and efficiency of adverse event reporting, physician peer review, and report distribution. This individual ensures absolute compliance with state and federal reporting mandates (HCAI, TJC, CMS) and leads the organization in achieving high-reliability performance through advanced clinical analytics and performance improvement methodologies.

Requirements

Master's Degree : MSN, MD or healthcare related field.
5 Years clinical experience to include experience with performance improvement.
2 Years management experience.
Solid understanding of CMS Conditions of Participation, The Joint Commission (TJC), CDPH Title 22, OSHA, and NQF standards across the continuum of care (Acute, LTC, Home Health, and Hospice).
Advanced knowledge of organizational structures required to be able to assemble cross functional teams geared toward performance improvement.
Proven ability to monitor and integrate evolving governmental and regulatory requirements into hospital operations.
Expert-level proficiency in process improvement concepts, facilitation techniques, and team-building tools.
Proficiency in Epic EHR, and Microsoft Office Suite, alongside the ability to manage complex regulatory databases.
Ability to leverage clinical analytics to drive quality initiatives and reportable performance metrics.
Highly developed interpersonal skills with the ability to facilitate, negotiate, and present effectively to diverse audiences, including the Board of Directors and public agencies.
Demonstrated success in partnering with physicians, executive management, and external business partners to drive clinical excellence.
Proven ability to prioritize high-stakes initiatives and manage complex projects under significant pressure.
Ability to communicate clearly in professional settings and deliver formal presentations to large audiences.

Nice To Haves

3 Years experience with physician services and clinical resource management (to include utilization review/case management/social services and discharge planning).
California Registered Nurse (RN) - CA Board of Registered Nursing -PREFERRED
Healthcare Accreditation Certification Program (HACP) - Center for Improvement in Healthcare Quality -PREFERRED

Responsibilities

Directs the entity’s Quality Assessment and Performance Improvement (QAPI) program and patient safety culture, ensuring the Quality Department serves as a central hub for strategic program development.
Collaborates with Clinical Effectiveness and executive teams to establish multi-year strategic roadmaps for quality, safety, and performance improvement.
Drives the adoption of Lean, Six Sigma, or similar methodologies to close performance gaps in external ratings and publicly reported measures.
Manages the Quality Department’s operational and capital budgets, ensuring resource allocation aligns with strategic safety goals.
Directs proactive risk management activities to maximize patient outcomes and minimize organizational liability.
Coordinates the data collection analysis and reporting processes related to proactive risk reduction to the Quality committee of the Board, Medical Executive Committee, Administration, Management and all appropriate staff to facilitate improvements in all key processes.
Collaborates with physician leaders to ensure quality of care and medical staff related issues.
Serves as the primary Administrator for the CMS QualityNet portal.
Oversees the integrity, accuracy, and timely submission of all federal and state-mandated clinical data.
Serves as a core member of the Executive Leadership Team, including participating in the Administrator on Duty (AOD) rotation.
Partners with the Regulatory Director to ensure 'always-ready' compliance with TJC, CMS, and state licensing requirements.
Collaborates with physician leadership to oversee Peer Review processes and ensure timely resolution of system-related clinical concerns.
Collaborates with Sharp HealthCare Legal/Risk Management/Claims Department on cases that may expose the organization to risk and helps implement appropriate mitigation strategies.
Acts as the designated Patient Safety Officer and primary liaison for Sharp HealthCare Legal and Risk Management regarding high-exposure events and mitigation strategies.
Collaborates with HIM, Coding Dept, and CDI to ensure the timely review of fallout cases.
Synthesizes complex clinical data into actionable insights for presentation to the Board of Directors, Medical Executive Committee (MEC), and senior administration.
Partners with Human Resources, CONE, and Sharp University to design and implement multidisciplinary training focused on patient safety culture and quality metrics.
Conducts consistent leadership rounding to facilitate open communication and real-time problem-solving with frontline clinical staff.
Directs the hospital's Patient Safety Event Response Team meetings.
Represents the hospital at system adverse event related committees and communicates plans and decisions.
Ensures the effectiveness and efficiency of risk reduction programs by training and dedicating resources for the cause analysis and FMEA processes.