Responsible for the overall administration and direction of quality, risk, and patient satisfaction functions. Plans and coordinates services and operations in the areas of Hospital-wide Performance Improvement, Hospital-wide Compliance with all regulatory agency regulations.  This position directs the performance improvement activities for the organization including risk management, patient care, quality/safety by providing ongoing consulting services throughout the medical center including but not limited to identification, prioritization, planning, measurement, validation, and analysis regarding performance improvement projects and programs.  This position has oversight for coordination for organization accreditation and regulatory compliance.  Coordinates SGVMC’s participation in external benchmarking databases and national and regional quality initiatives.  The position is accountable to County, State, and Federal agencies, as well as Joint Commission for maintaining compliance with all applicable laws, regulations, and standards.

1. This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

• Ensures compliance with quality assurance, risk/ safety and environmental procedures in accordance with regulatory and accreditation standards/requirements. 
• Leads the development, implementation, and ongoing activities that define a coordinated organizational approach to quality services and risk management.
• Directs performance improvement activities and ensures that the facility is survey-ready for unexpected and scheduled visits from the Joint Commission, CDPH and other regulatory entities.
• Plans, directs and coordinates services for department regarding operations, best practices, short and long term goals, and budgets.
• Supervises and coordinates the work of staff.   
• Responsible for effective management of operational and staffing matters, problem solving, training, supplies and equipment requisites, performance management, conflict resolution, coaching/disciplinary actions, and hiring/retention of staff.
• Advises the CNO of quality, risk, patient satisfaction, and performance improvement issues.
• Advises the CEO/CNO of risk management issues.
• Utilizes efficient managerial skills and critical thinking in order to optimize expense control.
• Ensures development of subordinates and succession planning.
• Recognizes consequences of decisions to budget.
• Responsible for positive staff morale, staff absenteeism management and low turnover.  Ensures qualified new hires and vacancies levels are appropriate.
• Prioritizes projects and uses time management to maximize efficiencies.
• Utilizes management process; gather data, identify issue (goal), identify remedy (objectives), implement and monitor to ensure expected results are achieved.
• Ensure standards are established and communicated to staff to ensure effectiveness of department.
• Clearly identifies the customer(s) they serve and establishes customer service/patient experience initiatives to ensure ultimate customer service is provided in order to achieve targeted outcomes.
• Possess the technical knowledge to appropriately develop spreadsheets, reports, and budgeting.  Demonstrates good project management skills to ensure targeted outcomes are achieved.
• Possess general knowledge of wage and hour regulations, record keeping, OSHA, workers’ comp, Department of Labor, EEOC, leave of absence laws, and complies with company policies and procedures.
• Works collaboratively with Human Resources to effectively handle administrative proceedings.
• Actively engages in self-improvement and training activities for subordinates to ensure the strategic goals and objectives are met.
• Demonstrates an understanding of organizational processes and procedures and adheres to the approved process.  Ensures subordinates follow approved process and procedures.  
• Other duties as assigned.

Education/Training/Experience/ Skills

• Masters degree in healthcare related field preferred.
• Minimum three years progressive supervisor experience in quality improvement and risk management
• Broad knowledge of medical and health sciences.
• Extensive knowledge of Joint Commission, state and federal regulatory requirements.
• Demonstrated ability to provide leadership and direction to interdisciplinary teams and multiple departments.
• Excellent written/verbal, interpersonal, communication, computer and presentation skills.

Licenses/Certifications

HACP or CPHQ Certification required