Southwest Healthcare - Murrieta, CA

Director of Quality

Job Summary

Director of Quality

We are looking for a registered nurse to step into the role of Director of Quality at a small health system in Southern California. You will lead the Quality department across two hospitals, both at just over 100 bed acute care facilities. 

You will be required to have your RN license, though a case could be made for one with strong experience and credentials to compensate for a lack of an RN license. A Bachelor’s Degree in Nursing is required, though a Master’s in Nursing, Healthcare Administration, or Business Administration is highly preferred, as well as a CPHQ certification. You will need at least five years of clinical experience in Quality Management and three years of leadership experience in Quality Management.

Southwest Healthcare

This small health system is comprised of five acute care hospitals and several non-hospital access points, including a multi-specialty ambulatory surgical center, several urgent care centers, and a multi-specialty medical clinic. The primary locations for this position will be over two 100+ bed acute care hospitals.

About the town

murrieta, CA


Public Schools




Good for Familes




Cost of Living


Outdoor Activities


Crime & Safety








Health & Fitness



Leapfrog Hospital Safety Scores

southwest healthcare

MeasureThe Hospital’s ScoreWorst Performing HospitalAvg. Performing HospitalBest Performing HospitalData SourceTime Period Covered
Dangerous object left in patient’s body What’s This?0.0000.3520.0150.000CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Air or gas bubble in the blood What’s This?0.0000.3580.0010.000CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Patient falls and injuries What’s This?0.6612.2290.4370.000CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Infection in the blood What’s This?0.0004.4621.0770.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
Infection in the urinary tract What’s This?2.5893.5160.8620.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
Surgical site infection after colon surgery What’s This?0.0003.1170.8220.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
MRSA Infection What’s This?2.0363.9181.0950.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
C. diff. Infection What’s This?0.7702.0660.4890.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
Death from treatable serious complications What’s This?124.85186.71143.2373.88CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Harmful Events What’s This?1.322.700.980.50CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Dangerous bed sores What’s This? *2.019.620.590.01CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Collapsed lung What’s This? *0.170.390.190.08CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Falls causing broken hips What’s This? *0.140.330.080.01CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Blood Leakage What’s This? *2.124.732.381.29CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Kidney injury after surgery What’s This? *0.883.060.920.27CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Serious breathing problem What’s This? *10.3446.916.731.15CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Dangerous blood clot What’s This? *3.747.743.401.11CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Sepsis infection after surgery What’s This? *5.038.704.151.53CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Surgical wound splits open What’s This? *1.021.980.810.30CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Accidental cuts and tears What’s This? *0.833.131.040.32CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
* This measure is a part of the Harmful Events Composite and is not used for scoring.

Process measures include the management structures and procedures a hospital has in place to protect patients from errors, accidents, and injuries.

MeasureThe Hospital’s ScoreWorst Performing HospitalAvg. Performing HospitalBest Performing HospitalData SourceTime Period Covered
Doctors order medications through a computer What’s This?1001591.771002022 Leapfrog Hospital Survey2022
Safe medication administration What’s This?1002591.221002022 Leapfrog Hospital Survey2022
Specially trained doctors care for ICU patients What’s This?100567.471002022 Leapfrog Hospital Survey2022
Effective leadership to prevent errors What’s This?120.009.23116.86120.002022 Leapfrog Hospital Survey2022
Staff work together to prevent errors What’s This?120.000.00115.87120.002022 Leapfrog Hospital Survey2022
Enough qualified nurses What’s This?88.240.0098.13100.002022 Leapfrog Hospital Survey2022
Handwashing What’s This?1001571.641002022 Leapfrog Hospital Survey2022
Communication with nurses What’s This?867589.8197CMS04/01/2021 – 03/31/2022
Communication with doctors What’s This?847689.7097CMS04/01/2021 – 03/31/2022
Responsiveness of hospital staff What’s This?755881.3094CMS04/01/2021 – 03/31/2022
Communication about medicines What’s This?694874.2187CMS04/01/2021 – 03/31/2022
Communication about discharge What’s This?816185.0795CMS04/01/2021 – 03/31/2022

Hospital Leadership

MEET THE staff

Karen Brandt-Mayo

Chief Nursing Officer

Mary Lo

Director of Infection Prevention

Official job description

southwest healthcare - Director of Quality

Industry: Healthcare / Health Services – Hospital Administration
Job Category: Medical / Health – Administration

The Director of Quality Management oversees and mentors staff in the collection, analysis, and reporting of data, facilitating improvement projects, assessing for and implementing risk reduction measures and assessing and coordinating activities related to achieving and maintaining ongoing regulatory compliance. Acts as the organizational point-person for interactions with regulatory agencies and provides facility-wide support for improving work processes, patient outcomes, risk reduction and acts as an educational reference.


Bachelor’s degree in Nursing from an accredited College or University.
Master’s degree in Nursing, Health Administration or Business Administration preferred.
Five (5) years of clinical experience in Quality Management required.
Three (3) years leadership experience in Quality Management required.
Acute care experience highly preferred.


Current license to practice nursing in the state of California
Current Basic Life Support (BLS) through the American Heart Association. Must be obtained within 90 days of start date.
Specialized professional certification in a related field preferred.

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Most frequent questions and answers

Yes. All of our open positions come with some sort of relocation allowance to help with the expenses of relocating. 

Yes. We will prep you for every interview you take. We know what our clients are looking for, so we will let you know what to expect and what experiences and accomplishments you should be sure to communicate to them in an interview.

Yes. If you connect us with another Infection Prevention professional that is interested in this position, and ultimately gets hired – we will send you a $500 referral bonus. 

Of course. We work to get you the highest possibly financial package – and communicate our progress throughout the process. We are financially incentivized to get you the most lucrative offer possible. 

Absolutely. We will review your resume before we submit it to the client to make sure it communicates everything it needs to.

First, everything we offer to our candidates is completely FREE. 

We operate as advisors and consultants for your Infection Prevention career. We’ve recruited in this industry for a long time and understand the profession as well as anyone.

If you decide you’d like us to represent you and apply for a position, the first thing our team will do is examine your resumé closely. We will fix up your resumé to ensure it communicates exactly what our client is looking for – demonstrating not only what you’ve been responsible for in previous Infection Prevention positions, but also how effective you’ve been in those roles. 

We have direct access to the hiring managers in the positions we search on which allows us to present your resumé directly to them, knowing exactly what they want to see in a candidate. We will keep you in the loop when this happens and what their initial feedback is. No more waiting in the dark hoping to hear back from HR.

Because of our relationships with the hiring manager, we have the ability to make a case for them to speak with you. It also allows us to get quick, honest feedback following each interview you have. And we will provide that feedback to you, good or bad.

In addition to preparing your resumé and presenting directly to the hiring manager, we also will prep you for each and every interview. Again, we know what our clients are looking for, so we will let you know what to expect and what experiences and accomplishments you should be sure to communicate to them in an interview.

In terms of the interview process, we’ll work with you and the client to get those scheduled during a time that makes sense for you.

Perhaps the most beneficial piece of being represented by Clutch Recruitment is that we’ll negotiate an offer for you – securing the highest possible offer the client can make. Don’t worry about your salary demands rubbing your future employer the wrong way;  we do all of that for you, ensuring a completely fair offer, without the awkwardness that potentially comes with it. We are financially incentivized to get you the highest possible offer, and we will ensure that happens.

Once you accept an offer, our work doesn’t stop. We’ll be there to talk you through your resignation and prepare you for how to handle a counter offer, along with all other complications that may arise. 

We have a large in house sourcing team that collects information from various databases online including LinkedIn, certification boards, and professional associations. 

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