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
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Leapfrog Hospital Safety Scores
southwest healthcare
| Measure | The Hospital’s Score | Worst Performing Hospital | Avg. Performing Hospital | Best Performing Hospital | Data Source | Time Period Covered |
|---|---|---|---|---|---|---|
| Dangerous object left in patient’s body What’s This? | 0.000 | 0.352 | 0.015 | 0.000 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Air or gas bubble in the blood What’s This? | 0.000 | 0.358 | 0.001 | 0.000 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Patient falls and injuries What’s This? | 0.661 | 2.229 | 0.437 | 0.000 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Infection in the blood What’s This? | 0.000 | 4.462 | 1.077 | 0.000 | 2022 Leapfrog Hospital Survey | 07/01/2021 – 06/30/2022 |
| Infection in the urinary tract What’s This? | 2.589 | 3.516 | 0.862 | 0.000 | 2022 Leapfrog Hospital Survey | 07/01/2021 – 06/30/2022 |
| Surgical site infection after colon surgery What’s This? | 0.000 | 3.117 | 0.822 | 0.000 | 2022 Leapfrog Hospital Survey | 07/01/2021 – 06/30/2022 |
| MRSA Infection What’s This? | 2.036 | 3.918 | 1.095 | 0.000 | 2022 Leapfrog Hospital Survey | 07/01/2021 – 06/30/2022 |
| C. diff. Infection What’s This? | 0.770 | 2.066 | 0.489 | 0.000 | 2022 Leapfrog Hospital Survey | 07/01/2021 – 06/30/2022 |
| Death from treatable serious complications What’s This? | 124.85 | 186.71 | 143.23 | 73.88 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Harmful Events What’s This? | 1.32 | 2.70 | 0.98 | 0.50 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Dangerous bed sores What’s This? * | 2.01 | 9.62 | 0.59 | 0.01 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Collapsed lung What’s This? * | 0.17 | 0.39 | 0.19 | 0.08 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Falls causing broken hips What’s This? * | 0.14 | 0.33 | 0.08 | 0.01 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Blood Leakage What’s This? * | 2.12 | 4.73 | 2.38 | 1.29 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Kidney injury after surgery What’s This? * | 0.88 | 3.06 | 0.92 | 0.27 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Serious breathing problem What’s This? * | 10.34 | 46.91 | 6.73 | 1.15 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Dangerous blood clot What’s This? * | 3.74 | 7.74 | 3.40 | 1.11 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Sepsis infection after surgery What’s This? * | 5.03 | 8.70 | 4.15 | 1.53 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Surgical wound splits open What’s This? * | 1.02 | 1.98 | 0.81 | 0.30 | CMS | 07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021 |
| Accidental cuts and tears What’s This? * | 0.83 | 3.13 | 1.04 | 0.32 | CMS | 07/01/2019 – 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.
| Measure | The Hospital’s Score | Worst Performing Hospital | Avg. Performing Hospital | Best Performing Hospital | Data Source | Time Period Covered |
|---|---|---|---|---|---|---|
| Doctors order medications through a computer What’s This? | 100 | 15 | 91.77 | 100 | 2022 Leapfrog Hospital Survey | 2022 |
| Safe medication administration What’s This? | 100 | 25 | 91.22 | 100 | 2022 Leapfrog Hospital Survey | 2022 |
| Specially trained doctors care for ICU patients What’s This? | 100 | 5 | 67.47 | 100 | 2022 Leapfrog Hospital Survey | 2022 |
| Effective leadership to prevent errors What’s This? | 120.00 | 9.23 | 116.86 | 120.00 | 2022 Leapfrog Hospital Survey | 2022 |
| Staff work together to prevent errors What’s This? | 120.00 | 0.00 | 115.87 | 120.00 | 2022 Leapfrog Hospital Survey | 2022 |
| Enough qualified nurses What’s This? | 88.24 | 0.00 | 98.13 | 100.00 | 2022 Leapfrog Hospital Survey | 2022 |
| Handwashing What’s This? | 100 | 15 | 71.64 | 100 | 2022 Leapfrog Hospital Survey | 2022 |
| Communication with nurses What’s This? | 86 | 75 | 89.81 | 97 | CMS | 04/01/2021 – 03/31/2022 |
| Communication with doctors What’s This? | 84 | 76 | 89.70 | 97 | CMS | 04/01/2021 – 03/31/2022 |
| Responsiveness of hospital staff What’s This? | 75 | 58 | 81.30 | 94 | CMS | 04/01/2021 – 03/31/2022 |
| Communication about medicines What’s This? | 69 | 48 | 74.21 | 87 | CMS | 04/01/2021 – 03/31/2022 |
| Communication about discharge What’s This? | 81 | 61 | 85.07 | 95 | CMS | 04/01/2021 – 03/31/2022 |
Hospital Leadership
MEET THE staff
Official job description
southwest healthcare - Director of Quality
Industry: Healthcare / Health Services – Hospital Administration
Job Category: Medical / Health – Administration
POSITION SUMMARY
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.
EDUCATION/TRAINING/ EXPERIENCE:
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.
CERTIFICATIONS/LICENSES:
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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