A Brief Overview The Administrative Director, Quality Management Accreditation and Clinical Effectiveness is accountable for providing overall leadership and direction for quality consulting, accreditation, regulatory and licensing preparation for the Stanford Healthcare enterprise and the University HealthCare Alliance (UHA). The leader is responsible for supporting peer review and care improvement committee responsibilities of the Chief of Staff and planning the quality assessment and performance improvement plan (QAPI) for the Board of Directors Quality and Service committee with the Vice President, Quality, patient safety and clinical effectiveness. The quality consulting responsibility provides structure and support for service quality committees and clinical pathway development.
This position is responsible for establishing and implementing the strategy and tactics which ensure that the hospital and the network is continually prepared for Joint Commission accreditation, federal and state regulatory surveys and compliance with all pertinent regulatory and accreditation requirements. This leader designs systems and processes to effectively support QAPI planning and quality councils across services including supporting the development of clinical pathways to reduce harm and improve patient safety in collaboration with operational and medical leadership.
This position serves as SHC's liaison with the Joint Commission, the California Department of Public Health (CDPH) state, regional and county offices, and the Centers for Medicare and Medicaid Services (CMS), and provides internal consultation and support across all departments and clinics regarding regulatory and accreditation standards interpretations, how to establish compliant processes and systems and to proactively identify any regulatory or patient safety issues and the tracking of action plans. This leader is responsible for successful completion of surveys, assuring operational readiness and follow-up procedures and documentation as required by regulatory bodies through investigations.
What you will do
Establishes and implements organizational regulatory guidelines and planning. Leads/forms continuous readiness plans and integrates accountability with operational and medical leadership. Manages compliance with related policies and procedures and recommends changes to policies and procedures to senior leadership.
Establishes oversight and monitoring plans to maintain compliance with all regulatory, accreditation and licensing requirements within Stanford Medicine’s care delivery system.
Develops relationships and integrates all team members into the team's work. Reports program findings, results, and changes at various settings and meetings. Forms relationships with various settings in the continuum of care based on program issues/work.
Responsible for overseeing the investigative process for evaluating adverse patient care events and near misses, as well as overseeing the external regulatory reporting required to CDPH.
Responsible for overseeing the hospital’s administrative manual and policy and procedure processes.
Oversees the insurance companies and Medicare Quality Improvement Organizations’ quality of care or complaint process for the hospital, working in conjunction with the Compliance-Billing unit, Health Information Management (HIM), Guest Services, Risk Management, Medical Staff, and the Office of General Counsel.
Responsible for serving as a liaison with other outside hospitals and delivery systems when dealing with quality of care or patient safety issues. This may require the position to share clinical information with the outside hospital and delivery systems in order to complete peer review or performance improvement activities
Plans and provides oversight for the peer review staff and management in support of the Chief of Staff and in alignment with medical staff bylaws. Ensures compliance with peer review standards in collaboration with the Chief of Staff and VP of Quality, patient safety and clinical effectiveness.
Provides support to the VP of quality, patient safety and clinical effectiveness to prepare for and manage Board of Director quality and service committee meeting preparation, minutes and documentation in compliance with CMS QAPI standards.
Manages planning and implementation of QAPI and quality management including deployment of the quality consultants to support quality councils and clinical pathway development to improve clinical outcomes and patient safety.
Collaborates with leadership, medical staff and service partners to ensure success in meeting regulatory requirements and maintaining a safe quality patient care setting.
Collaborates with department managers, physicians, and senior leadership to continuously improve operations, increase performance and streamline processes for continuous improvement.
Serves as the departmental contact for all licensing and regulatory associated events, acts as a liaison to address CDPH, district office, county, TJC and CMS issues and inquiries, and related issues in collaboration with Risk Management, Compliance, and the Office of General Counsel regarding accreditation, regulatory and patient safety issues.
Communicates requirements and standards in a timely manner to and provides consultation to all SHC departments for compliance to all accreditation and regulatory requirements and standards, ensuring consistency across the continuum; aligns processes and practices to maintain compliance with all National Patient Safety Goals.
Creates and maintains a dashboard for activities, performance, and action plans and provides leadership for the completion of open action items and collaborates with the management team on implementing action plans or in establishing active daily management practices.
Develops and evaluates the goals and prioritizes the work of the program in accordance with the strategic objectives of the hospital and the Quality, patient safety and clinical effectiveness department.
Develops and maintains relationships and effective communication with all levels of the medical staff, managers, and staff in order to facilitate problem identification and resolution; models exemplary customer service standards.
Provides education, training, and technical support to SHC and the medical staff in developing, implementing, and maintaining a state of regulatory compliance; translates standards, requirements, and policies into terms or processes meaningful to the target clinic, department or service.
Master's degree in health care and/or systems field with operational experience in healthcare is preferred.
RN or clinical degree; lean or process improvement certification preferred
Seven (7) years of progressively responsible and directly related work experience. Five (5) years of experience in leadership in large delivery systems or complex integrated system
Required Knowledge, Skills and Abilities
Knowledge of governmental and other regulatory standards, requirements, and guidelines, specifically, Joint Commission, CMS Conditions of Participation, Title 22, California Business & Professions code, California Health and Safety Code, California Medical Association, National Committee on Quality Assurance.
Experience in effective written and verbal communication and presentation to multi-professional executive groups.
Excellent interpersonal skills and leadership qualities.
Able to lead operational and medical staff and leadership independently and facilitate change across a large complex organization.
Knowledge of principles and practices of organization, administration, fiscal and personnel management.
Knowledge of local, state and federal regulatory requirement related to the functional area.
Knowledge of computer systems and software used in functional area.
Ability to analyze compliance with hospital accreditation standards and policies and ensure optimal compliance.
Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
Ability to provide leadership to staff and managers and influence others.
Ability to foster effective working relationships and build consensus.
Ability to prepare for, mediate and resolve complex problems and issues.
Strong written and verbal communication skills required.
Internal Number: R213023
About Stanford Health Care
We believe that great things happen when you put talented people together and then empower them to reach beyond the ordinary. Every day is an inspiration and an opportunity to lift up our patients with the kind of care that has earned us a worldwide reputation for excellence.
As an organization with more than 300 facilities throughout the Bay Area, we are a team united by our culture of respect. Our C-I-Care philosophy invites each employee to elevate the patient experience because every interaction is a chance to make a positive impact in the lives of those around us. Of course, that same commitment extends to the way we work together. We prize open communication and intensive collaboration as we strive to recognize every contribution. Because that's how true innovation happens again and again.