Fresno Surgical Hospital is known for excellence in surgical care delivery and patient satisfaction. Our goal is to provide a high quality of care through compassion to all we serve by creating a supportive environment for patients, clinical staff and employees.

The Director of Quality Management and Risk provides strategic and operational leadership to the performance measurement/reporting/improvement and Risk Management/Regulatory Compliance functions o

Salary Range: $62.50  - $86.54

Shift: M-F 8 hours

Minimum Education & Experience

• Graduate from an accredited school of Nursing.
• Additional course work in performance improvement and CQI desirable. 
•  Minimum of 5 years management experience of an acute care hospital for operational efficiency, strategic and financial planning, team building, quality/risk management and regulatory compliance or equivalent combination of education and experience.

Required License/Certification

• Current RN Licensure in the State of California
• BLS certification
• CPHQ certification preferred.

Required Skills

• Familiar with all related healthcare concepts, practices, policies and procedures.
• Knowledgeable of Joint Commission, HIPAA, AAHC and other healthcare governing bodies, both state and federal.
• Ability to understand basic quantitative concepts, analyze complex tasks, systems, problems and determine solutions.
• Ability to communicate effectively in English, both verbally and in writing.
• Ability to be flexible organized and function under stressful situation.
• Ability to maintain collaborative working relationships to ensure a positive and productive work environment.
• Ability to provide exceptional customer service.
• Able to communicate professionally at all levels within and outside of the organization.
• Able to effectively plan and prioritize work while dealing professionally and effectively with frequent interruption.
• PC competency, working knowledge of Microsoft Office Products (Word/Excel)

Essential Functions

• Responsible for planning and implementing the quality assurance performance improvement program to meet the needs of the hospital. Oversight of quality assurance performance improvement and CQI activities throughout the hospital. Facilitates performance improvement activities and CQI activities throughout the hospital.
• Oversees infection surveillance, infection control rounds and monthly hand hygiene audits.
• Oversight of Quality, Medical Staff Peer Review, Risk Management, Infection Prevention, and Medical Staff Office to ensure optimal performance and to provide direction/guidance on flow and departmental issues.
• Demonstrates effective organizational skills through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team and Governing Body to facilitate an effective hospital wide QAPI program.
• Chairs Hospital Wide Quality Committee and attends Medical Staff Peer Review meetings, Infection Prevention meetings, Medical Staff and Leadership meetings.
• Responsible for the hospital’s Emergency Disaster Preparedness in conducting disaster drills, as required by Joint Commission. Educating staff on Hospital Incident Command System (HICS) and ensuring that the hospital's emergency and safety plans are reviewed and compliant with all regulatory agencies.
• Provide leadership in the design and implementation of leading edge strategies that align FSH measurements and improvement initiatives with emerging national and state requirements and opportunities related to HIT/HIE; “meaningful use”; nationally endorsed performance measures and payments reform.
• Serves, in conjunction with the FSH infection prevention nurse to ensure that all quality and benchmarking surveys that we currently submit data to are kept current and the data is submitted on time and in a manner consistent with the mission of FSH.
• Responsible for clinical identification, risk evaluation and coordination of corrective action implementation related to risk issues. Provides intervention and education related to risk management issues to promote safe work practices and quality care and services; in an environment that is beneficial to the safety, health and well-being of all patients, visitors and hospital staff.
• Coordinates risk programs with all hospital departments, and administration. Reports real and potential risk situations to the Governing Body, medical staff, administration, hospital departments and committees, as appropriate. Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services.
• Serves as the Risk Manager for FSH and is accountable for managing and coordination activities of risk management to ensure that FSH maintains on optimum level of preventative risk management.
• Serves as the Patient Safety Officer and is the Chair of the Patient Safety Committee. Responsible for identifying patient safety risks and hazards, ensuring appropriate mitigation of those risks, and overseeing the appropriate response to serious preventable harm events.
• Serves as a resource for staff regarding Risk Management issues/concerns.
• Utilizes systems for risk identification, investigation and reduction
• Collects, evaluates, follow-up on all occurrence reports; distributes relevant data regarding incidents/injuries.
• Works in collaboration with Medical Staff and CNO to follow-up on patient complaints/grievances while maintaining data/log and reporting data to the Medical Staff Quality Committee.
• Facilitates/assists with general and professional liability claims; interfacing with defense legal counsel.
• Works in collaboration hospital management and Facilities manager as the Safety Officer. Responsible for a safe environment for all employees in the workplace. 
• Incorporates OSHA standards into the work environment. Conducts an annual Failure Modes and Effects Analysis.
• In conjunction with the CNO responsible for all regulatory and accreditation involving the Joint Commission and the CDPH. Ensures that the facility is in perpetual compliance with Title 22 and Joint Commission regulations and standards by monitoring FSH standards of practice and providing ongoing feedback to FSH leadership and medical staff.
• Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.
• Other duties as assigned.

Fresno Surgical Hospital complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce.  If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date.