Job Description

Overview

Monterey Park Hospital, a 101-acute care facility located in the San Gabriel Valley of Los Angeles County, is seeking a Director of Quality and Risk for our Quality Assurance Department. This is a full-time, exempt position reporting to the Chief Operating Officer.

Responsibilities

The Director of Quality and Risk Management initiates and oversees the development of comprehensive safety, quality, and performance improvement programs, working in collaboration with nursing and medical staff leadership. The Director provides strategic oversight of proactive and reactive patient safety activities, including RCA, FMEA, and Sentinel Event Alerts in regards to the facilitation of process planning, implementation, and evaluation of the effectiveness of process changes. The Quality and Risk Management Director supports the medical staff peer review process, FPPE, and credentialing. She/he ensures the Hospital is survey-ready at all times to maintain accreditation and licensing, provides education to Administration, Hospital leadership and staff on regulatory compliance. This position reports to the Chief Operating Officer. Additional responsibilities include the following:

• Oversees the collection and submission of quality data reported internally and to external agencies.
• Develops and implements strategic plans for Quality and Patient Safety annually.
• Coordinates the Quality/Patient Safety Council activities in collaboration with the Council Chairperson. Communicates pertinent reports to the Medical Staff and organization leaders.
• Works closely with the Medical Staff office to ensure that agendas and reports for the Quality Council and Committee meetings are complete and prepared in a timely manner.
• Leads and supports Performance Improvement Teams.
• Recommends and facilitates changes within the Hospital to improve patient safety based on identified risks.
• Utilizes the Hospital’s Performance Improvement Model, PACE, to coordinate the redesign of the process and/or underlying systems to minimize the risk of undesirable variation or to protect patients from potential harms.
• Follows critical analysis and identification of failure mode (process variation) methodology.
• Measures and evaluates effectiveness of quality and patient safety programs using established goals. Prepares annual reports for the Governing Board.
• Manages legal cases with AHMC Legal Counsel.
• Responsible for Incident Management monitoring and response (portal).
• Responsible for 24-hour administration of services.

Qualifications

Bachelor's degree in a health-related field required. Master's Degree preferred.

Certified Professional in Healthcare Quality (CPHQ) preferred.

Minimum of three years working in a healthcare Quality Improvement and Risk Management department required. Experience with survey preparation required.