Accreditation, Regulation & Quality Director

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.

• Directs Medical Center activities and programs for hospital and ambulatory sites which include focus areas such as accreditation, regulatory, risk, patient safety and infection control.


• 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).


• AR&L Responsibilities Include:


• 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.


• Patient Safety/Risk Responsibilities Include:


• 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.


• Kaiser Permanente conducts compensation reviews of positions on a routine basis.  At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.  Such changes are generally implemented only after notice is given to affected employees.

Qualifications:

• Minimum five (5) years of combined experience in quality, risk management, patient safety, infection prevention, accreditation/regulation, licensing, AND clinical operations leadership/management in a healthcare setting.

• Bachelors degree in health care administration, nursing, or public administration or related field required.

• N/A

• Experience designing, developing, implementing physician management programs.
• Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality, risk and patient safety.
• Demonstrated subject matter expertise in performance improvement methodologies, ability and desire to integrate PI principles into work processes; demonstrated leadership, project management, facilitation, problem solving, and communication skills.
• Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques.
• Effective communication, negotiation and leadership skills.
• Must be able to work in a Labor/Management Partnership.

• CPHQ, HCAP, CPPS, CPHRM and/or project management certification in related field preferred.
• Experience in large integrated multi-faceted health care system with large medical group or in an academic medical setting.
• Masters Degree preferred.

Salary : $155,900 - $201,740