Monterey Park Hospital, located in the San Gabriel Valley of Los Angeles, is a 101 bed acute care community hospital. Monterey Park Hospital has provided our community with advanced medical and culturally sensitive healthcare services for over 50 years. Monterey Park Hospital is recruiting for a Full-Time Director of Quality and Risk. This position reports to the Chief Operating Officer.

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 Director supports the medical staff peer review process, OPPE 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; The Director develops and implements strategic plans for Quality and Patient Safety annually.
• Coordinates the Quality/Patient Safety Council, 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 Medical Staff 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 that undesirable variation or to protect patients from the effects of that undesirable variation. Follows critical analysis and identification of failure mode (process variation) methodology.
• Supports and encourages error reporting throughout the Hospital through a non-punitive error reporting system.
• Measures and evaluates effectiveness of quality and Patient Safety Programs using established goals. Prepares an annual report for the Governing Board.
• Ensures that care provided meets medical necessity criteria as established by the payors.
• Manages legal cases with AHMC Legal Counsel.
• Ensures that an effective system of communication is in place to enhance both internal and external working relationships and work flows.
• Responsible for Incident Management System monitoring and response.
• Responsible for 24-hour administration of services.

Education: Bachelor Degree in health related field required.

Licensure/Certification: Certified Professional in Healthcare Quality (CPHQ) preferred. California RN or LVN license preferred.

Experience: Minimum three years working in a healthcare Quality Improvement or related field preferred.