Vice President (VP) of Quality and Patient Safety (LBMMC), Quality Assurance - FT/Days
MemorialCare Health System
Location: Long Beach, California
Internal Number: LON009165
At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.
The Vice President (VP) of Quality and Patient Safety will work collaboratively with the Chief Quality Officer (CQO) to oversee all clinical quality and patient safety activities for Long Beach Medical Center and Miller Children's and Women's Hospital Long Beach. This position is responsible for continuous improvement of safety, quality and satisfaction in the care delivered. The VP will facilitate and act as a resource for the administrative team, directors, medical staff and service lines to improve patient outcomes.Oversight responsibility for all regulatory requirements, licensing and accreditation surveys. Works together with CQO for oversight of Regulatory/Accreditation, Epidemiology, Chaplain Services, Patient Relations/Interpreter Services and Patient Experience.
Essential Functions and Responsibilities of the Job
With the CQO, the VP of Quality and Patient Safety will position the organization as a national leader in clinical quality and patient safety on our journey to organizational to high reliability.
The VP will continuously assess, review, evaluate, develop and implement programs to expand what the organization is doing to achieve the bold goals as outlined by the MemorialCare Strategic Plan.
Accountable for the regulatory compliance on an ongoing basis for all state and federal certification, licensing and accreditation surveys including but not limited to CMS, Joint Commission, CDPH, GAC, California Children’s Services and others as assigned. Ensures that the organization remains in a state of survey readiness at all times.
Provides guidance and is responsible for ensuring all external data submission is accurate, complete and timely for external reporting, including but not limited to QNET, Joint Commission Core Measures, CMQCC, NHSN, Health Plans and Payors.
Obtains Lean Leader Certification and acts as a Lean Leader Coach and resource for facilitating performance improvement and patient safety.
Provides oversight of the campus Epidemiology programs, Patient Relations and Chaplain Services.
Responsibility for hospital licensing and regulatory requirements including GAC license and annual renewal, flexibility program request and required signage throughout the organization.
In collaboration with the CQO, provides quality performance improvement consultation to hospital service lines.
Provides campus oversight with CQO in collaboration with clinical risk management and event response.
Responsibility for collaboration with the Medical Staff office in the MPEC process.
Participates actively on Medical Staff Joint QRC/CPI Committee and ensures that all required PI data is reviewed timely.
Ensure quality performance to drive towards high reliability with a goal of zero harm.
Participates in campus intensive assessments and root cause analysis reviews with the CQO/CMO to identify system issues.
Improves data monitoring tools and metrics for analyzing and reporting Crimson data to enhance quality initiatives including the development of dashboards for key quality improvement initiatives.
Participates in research in healthcare delivery science, infection prevention, quality outcomes and submits presentations on behalf of MemorialCare at state and national meetings.
Acts as organization wide consultant for Regulatory Standards including but not limited to JC, CMS, CCS, CDPH, Licensing and Certification and Title 22.
Guides and actively participates in assuring compliance with California Children's Service's Standards and coordinates the CCS site visits involving appropriate leadership at LBMC and MCWH.
Regulatory, Accreditation, Licensing and Environment of Care:Ensures all state and federal regulations across both hospitals are met.Identify organizational opportunities to increase survey readiness for all leaders and staff. Create remediation action plans to address areas of opportunity for improvement identified during federal (TJC, CMS) surveys and state (GACHLS and CDPH) survey. Create dashboard of prioritized Environment of Care (EOC) issues identified with enhanced focus on infection control and quality oversight of EOC program.
Patient Experience Program: Oversight of service departments that enhance the patient experience; track and monitor patient improvement initiatives with priorities targeted to improve patient experience.
Epidemiology: Ensure infection prevention program provide the most effective evidence-based guidelines. Works with clinical teams to reduce hospital acquired infections and drive towards goal of zero harm.
Patient Relations/Interpreter Services/Guest Services/Volunteers: Oversees the development of guest relations with patients, visitors, physicians and staff to ensure the best patient experience.Support diversity plan and interpreter services for limited-English proficient patients and deaf/hearing impaired population.Oversee PBX/Caller Experience, including timely communications/pages of emergency codes.
Track and complete all CDPH annual and new licensing needs at LBMC & MCWH. This includes additions to the hospital license, renewal of GAC license, request for and renewal of flexibility programs.