1+ months

Clinical Director, Quality Services

Kaiser Permanente
Santa Rosa, CA 95403
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Accountable for direction and implementation of activities and programs for hospital, ambulatory sites, associated alliance hospitals and other non-KFH facilities in one or more of the following areas:  accreditation, risk management, and infection control. Aligns programs with performance initiatives and strategic priorities as defined by leadership.  Develops strong collaborative leadership relationships with TPMG, external regulatory agencies, accreditation bodies, employer groups. Directs and implements organization-wide systems and processes for improvement, in collaboration with clinical and administrative personnel.
Essential Responsibilities:
  • Directs Medical Center activities and programs for hospital and ambulatory sites which include quality, as well as other focus areas such as accreditation, regulatory, risk, patient safety and/or infection control.
  • Uses clinical licensure to evaluate and train registered nurses on performance and processes.
  • Develops action plans for improvement of nursing practice.
  • Establishes and maintains highly effective working relationships with key stakeholders and departments, including physicians, clinical and administrative leaders, front-line staff, and external regulatory and accrediting bodies.
  • Directs the daily operations of the department, including, allocating resources and priorities for staff, facilitating team development; motivation and problem solving; establishing and meeting department and organizational goals and ensuring workplace safety initiatives are implemented.
  • Hires, orients, develops, coaches, appraises, rewards and retains competent personnel.  Manages the department budget.
  • Directs programs that are consistent with cultural diversity, healthcare literacy issues and language.
  • Directs and manages a strategic data management program and utilizes data to improve performance of all worker and patient safety programs.
  • Applies the appropriate performance improvement methodology to address improvement opportunity (eg. MFI, Lean DMAIC).
  • Plans and directsthe implementation of programs across the facility, which encompass strategic planning for the achievement of quality outcomes.
  • Assists leader with reports on member utilization, network quality  and medical staff credentialing/privileging functions, contract quality measures contained in the service area contracts, the care and service outcomes of contracted practitioner/provider organizations, and the member functions of complaints, grievances and appeals associated with timely care and service delivery quality.
  • Directs and supports the use of evidence based guidelines, criteria and other clinical tools to reduce variation in clinical practice and to optimize clinical outcomes.
  • Directs member grievance and complaint review process.
  • Direct and implement reviews to meet legal and regulatory requirements for Hospital/Health Plan.
  • Collaborates with medical staff to manage the medical staff functions including peer review and the practitioner performance review and oversight process.
  • Directs and implements accreditation, licensing and regulatory activities and systems.
  • Responsible for meeting all requirements, ensuring compliance in all applicable settings, and managing reliable processes for timely and accurate submissions.
  • Directs and implements risk mitigation activities and corrective action plans.
  • Identifies new legislations' effect on Hospital/Health Plan and implements programs that ensure alignment with new legislation.
  • Directs implementation of reliable systems that support evidence based optimal care in both hospital and non-hospital setting.
  • Directs and implements comprehensive infection control programs for surveillance prevention, data analysis and reporting, and control of infections across hospital, medical group, and environmental support departments.
  • Develops and plans for patient safety and risk management programs and development of responsible reporting mechanisms.
  • Ensures that the environment of care is safe, functional, supportive and effective both for the delivery of patient care and protection of the worker.
  • Collaborates with medical staff to direct peer review, practitioner performance review and oversight process.
  • Implements and directs a safe culture through responsible reporting of unusual events, human factors training, and design of systems for safe and reliable practices.
  • Takes appropriate actions when errors occur and cause harm to members, patients staff and/or the organization.
  • Directs, implement s and evaluates a comprehensive risk management plan for the facility to reduce or eliminate the potential for financial loss to reduce medical errors.
  • Directs appropriate KFH/HP oversight to address for hospital/health plan risk issues.
  • Collaborates with the ombudsman to ensure rapid resolution of patient concerns and grievances.
  • Directs the significant event management program.
  • Posted: 2020-04-03 Expires: 2020-07-04

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    Clinical Director, Quality Services

    Kaiser Permanente
    Santa Rosa, CA 95403

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