Education and Work Experience:

• Bachelor's Degree in a healthcare-related field or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Five years' technical experience: Preferred
• One year's leadership experience: Preferred

Essential Functions:

• Assists with unscheduled survey visits from TJC, CDPH, Partnership and CMS and organizes and prepares unscheduled survey response correspondence and plan of action in a timely and accurate manner Collaborates with Quality/Risk Manager, Network Director, Regional Director of Accreditation, and Infection Prevention and Other related Clinic regulatory issues. Maintains responsibility for the planning and delivery of staff education including orientation, continuing education, annual review, competencies and other education as required by regulatory agencies and organization policy. Collaborates as necessary in the planning and presentation of educational offerings for clinical and other hospital personnel.
• Develops programs/processes related to Quality Management. Responds to clinical patient or family concerns and/or complaints as evidenced by a personal visit/or phone call, to patient and follow-up through written complaint process. Establishes, reviews, updates and coordinates as necessary, programs of quality assurance, infection prevention, and quality control for the departments. Responsible for the timely review of medical records using established and approved criteria, ensuring the evaluation of identified conditions and implementation of follow-up measures for Quality and Risk related issues. Develops and implement the infection control/prevention program in accordance with professional, legal, organizational and accreditation standards.
• Provides annual reports regarding performance Improvement and Quality programs. Participates in quality committees with accountability for distribution of organizational communication. Monitors quality control programs, computing rates and reporting data on priorities in the annual risk assessment. Collaborates with departments as necessary. Maintains responsibility for organizing the monthly clinical lead meetings for all staff which include providing necessary regulatory updated, education, performance improvement, patient satisfaction results overview.
• Oversees compliance with Sentinel Event Alerts. Communicates updates to leadership. Works with champion for each event to assure implementation of necessary changes and/or education. Oversees the Performance Improvement process in accordance with industry standards including individual department and hospital-wide QA/PI programs and the coordination of required performance/quality indicator data collection, analysis and reporting for TJC, CMS, CDPH and other reporting organizations. Presents data to Performance Improvement Committee for analysis and identification of performance improvement opportunities.
• Oversees TJC/CDPH review process. Completes documentation for survey preparation. Oversees communication with accrediting and regulatory agencies. Effectively coordinates the process during an actual survey. Coordinates completion of the survey plan of correction in an effective and timely manner. Responsible for educating management and staff about TJC/CDPH/CMS standards and regulations. Monitors changes in standards and regulations. Conduct program according to APIC standards, federal and state laws and accreditation bodies governing such programs.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.