Manager, Quality, Full Time, Day, Paradise

Job Description

Located in beautiful Northern California, Adventist Health Clear Lake has been a leading healthcare provider in Lake County since 1968. We are comprised of a 25-bed critical access hospital and provide primary and specialty care services at clinics throughout the area to best serve our community. Lake County is home to Clear Lake, California's largest natural freshwater lake, surrounded by charming small towns, beautiful mountains, vineyards and orchards. This area is perfect for outdoor enthusiasts, with some of the best bass fishing, rural trails for hiking and biking, all the while being only two hours from the San Francisco Bay Area, Sacramento Valley or Pacific Coast.

Job Summary:

Provides content expertise and consultation on Performance Improvement, Regulatory compliance, Quality/Risk and Clinical Oversite to the outpatient clinics. Provides clinical oversight, guidance and education to the outpatient clinical staff including providing guidance related to employee relations and hiring decisions. Oversees the Quality Department that evaluates the services provided and the results achieved as compared with accepted standards. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment.

Job Requirements:

Education and Work Experience:

• Bachelor's Degree in a healthcare-related field or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Five years' technical experience: Preferred
• One year's leadership experience: Preferred

Essential Functions:

• Assists with unscheduled survey visits from TJC, CDPH, Partnership and CMS and organizes and prepares unscheduled survey response correspondence and plan of action in a timely and accurate manner Collaborates with Quality/Risk Manager, Network Director, Regional Director of Accreditation, and Infection Prevention and Other related Clinic regulatory issues. Maintains responsibility for the planning and delivery of staff education including orientation, continuing education, annual review, competencies and other education as required by regulatory agencies and organization policy. Collaborates as necessary in the planning and presentation of educational offerings for clinical and other hospital personnel.
• Develops programs/processes related to Quality Management. Responds to clinical patient or family concerns and/or complaints as evidenced by a personal visit/or phone call, to patient and follow-up through written complaint process. Establishes, reviews, updates and coordinates as necessary, programs of quality assurance, infection prevention, and quality control for the departments. Responsible for the timely review of medical records using established and approved criteria, ensuring the evaluation of identified conditions and implementation of follow-up measures for Quality and Risk related issues. Develops and implement the infection control/prevention program in accordance with professional, legal, organizational and accreditation standards.
• Provides annual reports regarding performance Improvement and Quality programs. Participates in quality committees with accountability for distribution of organizational communication. Monitors quality control programs, computing rates and reporting data on priorities in the annual risk assessment. Collaborates with departments as necessary. Maintains responsibility for organizing the monthly clinical lead meetings for all staff which include providing necessary regulatory updated, education, performance improvement, patient satisfaction results overview.
• Oversees compliance with Sentinel Event Alerts. Communicates updates to leadership. Works with champion for each event to assure implementation of necessary changes and/or education. Oversees the Performance Improvement process in accordance with industry standards including individual department and hospital-wide QA/PI programs and the coordination of required performance/quality indicator data collection, analysis and reporting for TJC, CMS, CDPH and other reporting organizations. Presents data to Performance Improvement Committee for analysis and identification of performance improvement opportunities.
• Oversees TJC/CDPH review process. Completes documentation for survey preparation. Oversees communication with accrediting and regulatory agencies. Effectively coordinates the process during an actual survey. Coordinates completion of the survey plan of correction in an effective and timely manner. Responsible for educating management and staff about TJC/CDPH/CMS standards and regulations. Monitors changes in standards and regulations. Conduct program according to APIC standards, federal and state laws and accreditation bodies governing such programs.
• Performs other job-related duties as assigned.

Organizational Requirements:


Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

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About Us

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.