Organization:

SHSO-Administrative Payroll

Position Overview:

Works with the Chief Medical & Quality officer to drive industry-leading clinical Quality and Safety across all Sutter health assets (inpatient, outpatient, and Works with the Chief Medical & Quality officer to drive industry-leading clinical Quality and Safety across all Sutter health assets (inpatient, outpatient, and other) by setting metrics and targets, methodologies, and accountability guidelines for clinical effectiveness. Assists the CMQO in overseeing programs and policies as they relate to local, state, and national regulations concerning safety at the site of care delivery. Focusing on patient-related safety issues, is a trusted advisor in leading the evaluation of this information to identify causes, and recommend changes, policies, or programs. Works with the CMQO to develop new protocols and practices and ensure appropriate dissemination to providers across the system, including training programs meant to increase awareness of patient safety initiatives. Along with the CMQO provides expertise in collaborating with clinicians to improve processes and achieve better quality and clinical effectiveness outcomes. Collaborate with Human Resources and Environmental Health and Safety departments to facilitate an integrated approach to safety that protects both patients and staff, reducing harm and promoting a proactive culture of safety.

Job Description :

Education

Required

• Licensed Clinical Professional (MD, DO)

Preferred

• Certified Professional in Healthcare Quality (CPHQ)

• Certified Safety Professional (CSP) via ASP/GSP, CIH, OHST, or CHMM or Associated Risk Management (ARM)

Experience

• Extensive experience working with quality and risk management programs as typically acquired during progressive leadership roles over 5-7 years in a multi-facility, managed care environment with clinical operations.

• Experience as typically obtained in 5-8 years working as a licensed clinical physician with 3-5 years working in quality, patient safety or risk management in health care, preferably in a hospital environment.

• Solid experience in performance measurement, data analysis, and interpretation, as well as a working knowledge of regulatory and accreditation requirements.

• Proven experience in incorporating TJC surveys to improve the quality of care and services.

• Experience typically acquired during several years of OSHA-related experience.

• Expertise working with local, state and federal government agencies, regulatory bodies, and review boards.

• Proven experience in planning and implementation of patient safety programs, policy development and accident investigation.

• Solid experience in coordinating patient safety and loss prevention activities for a large employer with diverse work environments.

• Strong working base in continuous quality improvement (CQI) systems for medical and hospital staff within a large complex organization and demonstrated experience in interpreting raw data and conducting comparative analysis.

Knowledge

• Extensive knowledge of quality assurance, risk management, problem identification (driving to root cause), assessment and solving techniques.

• Understanding of and experience with Lean or other process improvement philosophies and methodologies.

• Solid understanding of business planning including analysis, statistics, budgeting, feasibility studies and implementation.

• Knowledge of state and federal regulations governing immunity for peer review confidentiality.

• Working knowledge of data analytics in clinical settings and the ability to interpret results for senior management.

• Current understanding ofindustry trends, health care laws, regulations, accreditation requirements and clinical standards of practice.

• Thorough knowledge of methodologies for severity adjustment such as Medicare Severity Diagnosis Related Groups (MS-DRGs), All Patient Refined Diagnosis Related Groups (APR-DRGs), and International Classification of Diseases (ICD) coding is required.

• Solid understanding of the Health Insurance Portability and Accountability Act (HIPAA) and Healthcare Effectiveness Data and Information Set (HEDIS).

• Certified Safety Professional (CSP) by the American Board of Certified Safety Professionals or possession of other applicable certification (i.e. designation as an Associate Safety Professional (ASP), Certified Patient Safety Officer (CPSO), Certified Industrial Hygienist (CIH), Certified Healthcare Safety Professional (CHSP), or possession of the National Safety Council's Advanced Safety Certificate (ASC).

• Working knowledge of hospital (clinical and physical plant) operations, industry principals, applicable governing body regulations and standards, including OSHA (Title 8 and 26, SB 198), Cal-OSHA, California Labor Code, Title 22, and The Joint Committee (TJC).

• Expert knowledge of patient safety science principles, theory, methods, standards, occupational health, and loss prevention programs.

• Strong working knowledge of Medicaid, Medicare and Marketplace healthcare products.

Skills

• Excellent leadership skills with the ability to lead the staff and leadership team toward changes that contribute to a culture of quality and safety throughout the enterprise.

• Superior attention to detail, with the proven ability for critical thinking in investigating and assessing complex safety issues, organizing and analyzing data, interpreting safety laws and regulations, and formulating constructive solutions.

• Strong analysis skills to determine organizational quality improvement needs and the capability to develop plans that tackle the issue while educating the appropriate parties.

• Ability to succinctly present complex reports and findings to management and diverse “lay” audiences, articulate solutions, and influence others toward achieving a common goal.

• Ability to interpret Joint Commission on Accreditation of Healthcare (JCAHO), Centers for Medicare and Medicaid Services (CMS), and Title 22 regulations/standards; working knowledge of medical care standards/practices.

• Solid influencing and negotiation skills to build consensus and motivate staff to action.

• Effectively collaborate with other departments to respond to quality issues, establish preventative measures and initiate process improvement efforts.

• Advanced level of computer competency in Microsoft Office Suite, as well as data management and statistical analysis software.

The primary office location of this position will be in Emeryville or Sacramento, California with travel throughout the Sutter Health footprint.

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

As Needed

Benefits:

Yes

Unions:

No

Position Status:

Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

1

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $224.76 to $304.09 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.