SUMMARY

The Quality and Regulatory Compliance Director is responsible for the program development, implementation, and management of Quality improvement initiatives, risk management, corporate compliance, patient safety and patient experience activities throughout the hospital district. This Director effectively engages everyone in the organization to improve quality performance and communicates all quality activities to the medical staff, Board of Directors, administration and staff. This position is responsible for gathering and reporting quality data to outside quality improvement organizations in an accurate and timely manner. This Director coordinates, investigates, and responds to customer complaints and patient-related issues. This Director is also responsible for maintaining regulatory compliance of the organization and has a working knowledge of State and Federal regulations.

QUALITY AND REGULATORY COMPLIANCE RESPONSIBILITIES:

**This is not an all-inclusive list and is subject to change, elimination and addition of responsibilities in response to the ever changing climate of hospital regulation and quality.

• Preparation for and coordination of regulatory surveys
• Regulatory survey response and compliance
• Regulatory Self-reporting activities and follow-up
• Quality Review Report review and follow-up
• Failure Mode and Effect Analysis and Root Cause Analysis investigation and reports
• Complaints: investigation and follow-up
• Patient satisfaction surveys
• Beta HEART program
• Service Excellence Initiative oversight

Committees

• Continuous Quality Improvement Program
• Nurse Advisory and Regulatory Compliance Committee
• Board of Directors Quality Committee
• Peer Review chart prep and committee participation
• Medication Error Reduction Program
• Falls Committee
• Wound Care Committee
• Fire, Life, Safety/Emergency Operations Committee
• Team Walk Rounds
• Beta HEART Steering Committee
• Service Excellence Council
• CHA Certification and Licensing Committee
• Medical Executive Committee
• Infection Control Committee
• Medi-Tech Clinical Systems Optimization Committee
• Patient & Family Advisory Council
• Corporate Compliance Committee

Data Collection and Reporting

• Emergency Department Transfer Communication
• Departmental Quality Dashboards
• Patient Experience Surveys
• MBQIP, NHSN, HQR (IQR, OQR), eCQMs, TJC DDSP
• Dexur - IQR, OQR, SIERA files
• HQIP - IQR, OQR
• Survey Solutions
• Ongoing Professional Practice Evaluation

Additionally

• Department Manager meeting
• New Employee Orientation - Quality, Service Excellence
• Policy review and development
• FLEX and SHIP Grant management
• Bachelors' degree required
• Experience required

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION/EXPERIENCE

Bachelor's degree required

Experience Required

CERTIFICATES, LICENSES, REGISTRATIONS
• Current RN License in California or ability to obtain CA license within 30 days of hiring is required
• CPHQ certification preferred