Responsibilities Palmdale Regional Medical Center serves the region by providing high quality medical services to residents of the Antelope Valley, Santa Clarita Valley and surrounding communities.The Rehabilitation Institute, the hospital features 184 licensed acute care beds as well as inpatient and outpatient surgery, an Advanced Primary Stroke Center, cardiac services featuring a STEMI Receiving Center (heart attack) and a 35-bed 24-hour emergency department. Palmdale Regional Medical Center believes in "Community Service Excellence" and supports nonprofit agencies such as the American Cancer Society, United Way, the Antelope Valley Boys and Girls Club and performing arts organizations. Building a Healthier Community...Big Changes are already here! This opportunity offers the following: Challenging and rewarding work environment Growth and development opportunities within UHS and its subsidiaries Competitive compensation Excellent Medical, Dental, Vision and Prescription Drug Plan 401k plan with company match SoFi Student Loan Refinancing Program Student Loan Repayment Assistance Program Essential Job Duties: To provide administrative, technical, and coordinating support to the Quality Management program. The Director of Quality Management plans, implements, and manages performance improvement and patient safety initiatives in the organization. Qualifications Requirements: Minimum five (5) years experience in acute care quality management, with at least years in a supervisory role. Experience in peer review required. Certified Professional in Healthcare Quality (CPHQ) desired. Graduate of an accredited School of Nursing or Equivalent. Bachelor’s degree required. For RN candidates: Current, active Registered Nurse licensure in the State of California. For non-RN candidates: Appropriate current, active clinical registration/certification. Current Basic Cardiac Life Support certification. POSITION SPECIFIC RESPONSIBILITIES: Oversees the effective development, implementation, and evaluation of the Quality Management Program. Assesses for compliance of regulatory requirements, disseminates information on new regulatory requirements, coordinates making changes to policy/practice related to meeting requirements, including contract review, coordinates accreditation activities and inspections and acts as org contact with regulatory agencies. Assists various services in developing criteria for monitoring performance and following up on findings implementing corrective action plans while providing data-driven information hospital wide. Oversees the medical staff peer review process, reappointment clinical profile reporting, and addressment of disruptive physicians by working closely with the medical staff leadership. Promotes a culture of safety, proactive prevention of risks and infections, and philosophy of continuous improvement. Coordinates the review and investigation of risk claims cases, depositions, gathering of information and keeping senior leaders apprised of such cases through appropriate reporting to senior leadership, medical staff leadership, and corporate leadership as it relates to performance improvement, risk management and infection prevention. Coordination and linkage of Performance Improvement, Clinical Quality and Service Excellence, Risk Management, Infection Prevention and Regulatory requirements. This includes the execution of shared processes of MIDAS (Event) reports, ENS (Initial and Follow up) Root Cause Analysis, Failure Mode and Effects Analysis (FMEA), AHRQ Culture of Safety Survey, Patient Safety Council, Patient Safety Alerts, oversight of PSES Member site and Member Workforce Education & Confidentiality Agreements, and needed. Clarifies outcomes from survey data or PI reviews with various services when findings are unclear or noncompliant. Maintains current competency related to Performance Improvement, Risk Management, Patient Safety, and Joint Commission, DHS, local agency C MS Regulations. Participates and/or leads team activities toward achieving improvements in performance hospital-wide. Networks with other professionals in the field. Maintains confidentiality of information. Establishes and maintains effective working relationships with customers, i.e. peers, staff, medical staff, and public agencies, etc. Promotes a culture of safety, proactive prevention of risks and infections, and patient-centered care philosophy of continuous improvement. Provides staff education and acts as a facility resources EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.