Sutter Health · 2 weeks ago
Director, Quality & Patient Safety (Acute)
Vallejo, CA
Full-time
Onsite
Director/Executive
$0/hr - $0/hr
12+ years expSutter Health is a healthcare organization committed to quality and patient safety. The Director of Quality & Patient Safety will work collaboratively with various medical and operational leaders to develop and implement quality management programs and ensure compliance with safety regulations.
Health CareHospitalNon Profit
Responsibilities
Develops, implements, and provides coordination of entity's continuous quality improvement (CQI) program
Utilizes observational skills and other appropriate data sources to gather information on clinical and operational processes to improve the organization’s processes, recommend solutions, and implement action plans
Integrates CQI with the medical staff structure and activities, and implements coordination of the performance improvement program across all departments and including the board of directors
Provides education and direction to hospital management and medical staff leaders in CQI concepts and techniques, and works to continuously integrate quality improvement functions across departments and with medical staff and between the medical staff and the patient service departments
Provides independent project leadership on assigned projects, including focus on coordination of initiatives related to process improvement and redesign
Deconstructs processes, assesses operations, and implements recommendations for developing best practices for implementation and develops baseline and ongoing measurements to track improvement
Plans, organizes and coordinates all aspects of the patient safety program within the facility
Is responsible for developing and maintaining a comprehensive patient safety program including identification, evaluation and coordination of corrective action implementation related to identified safety issues in conjunction with the risk management leadership
Maintains knowledge of regulatory/accrediting agencies, statutes and reporting requirements
Collaborates with risk management leadership in identification and reporting of real and potential patient safety issues
Maintains direct responsibility to make timely reports to leadership, medical staff, administration, hospital departments and committees
Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce harm/potential harm associated with the provision of patient care
Acts as the facility patient safety officer
Is responsible for the facilitation and conduct of the harm measurement system for safety events
Manages the recording and reporting of harm events utilizing the proscribed tools and methods
Coordinates with the risk management leadership on risk management and patient safety activities which include but may not be limited to coordinating those systems necessary for identification, evaluation, monitoring, reduction and/or elimination of patient harm, including the conduct of root cause, apparent cause, and common cause analyses based on patient harm/patient safety/risk management issues/events
Provides counseling and education to the administrative and management staff, clinical personnel, and medical staff members related to the patient safety day-to-day operations
Manages analysis and reporting of patient safety data to the organization, leadership, and Sutter Health
Oversees organizational compliance with regulations governing rules of accrediting bodies as it relates to acute care hospitals & related services
Develops and implements strategies that support continuous survey readiness
Establishes, and defines program parameters, and monitors results of quality management standards in conjunction with leadership
Facilitates preparation of surveys and participates as administrative liaison in all surveys effecting licensure and/or accreditation
Maintains knowledge in Joint Commission, Centers for Medicare and Medicaid Services (CMS), State and other applicable requirements and provides education to administration, management, staff and medical staff on new requirements
Coordinates the accreditation and licensure activities for entity including ongoing readiness activities and participation in mock surveys
Completes self-assessment tools required by Joint Commission in coordination with organizational leadership
Facilitates the development of action plans to mitigate survey findings and submits to the appropriate agency upon review and approval of leadership
Manages accreditation readiness staff
Facilitates and collaborates with medical staff leadership and peer review staff to coordinate all aspects of the entity physician peer review program
Functions in a collaborative manner with all hospital disciplines impacted by the peer review process
Responsibilities include assisting in the monitoring, collection, analysis, security and reporting of all pertinent data findings related to physician performance as determined by the individual medical staff departments
Identifies opportunities to improve patient outcomes, safety and quality, and actively supports the elements of extending excellence
Assists medical department leadership in determining criteria for conducting, ongoing professional practice evaluation (OPPE), triggers indicating need for, focused professional practice evaluation (FPPE) and on-going clinical monitors
Assists the medical staff in identifying data to be collected, method of data abstraction and reporting format
The type of data to be collected is determined by individual departments and approved by the organized medical staff and governing body
Performs on-going physician performance monitoring ~ to include data collection and trending physician clinical performance with an internal reporting system including dissemination of information to medical staff
Validates peer review data ensuring completeness and accuracy on an on-going basis to support patient safety organizational activities
Prepares and participates in peer review committees in collaboration with department chairs
Participates in preparation physician re-credentialing reports
Facilitates FPPE, focused professional practice evaluation process as defined by, and the direction of the organized medical staff leaders
Attends medical staff meetings to facilitate integration of functions across both medial staff and hospital departments and/or support the medical staff peer review and the hospital’s performance improvement processes
Provides leadership oversight to the medical staff services manager/department in conjunction with the entity chief medical executive
Assures medical staff credentialing activities support patient safety and all applicable requirements per bylaws, rules and regulations
Assures adequate and competent support of medical staff meetings
Assures OPPE process is effective and maintained on schedule
Evaluates effectiveness, timeliness, accuracy, and appropriateness of staff functions by reviewing activities with each employee on an ongoing basis
Understands the roles and responsibilities of each position/function within the integrated quality services (IQS) department and provides direct supervision to IQS staff
Conducts interviews and hires for vacant positions within the department
Completes performance evaluations for departmental staff in a timely manner, reflecting an accurate assessment of employee performance in comparison with established standards
Assures that all personnel actions are in conformance with the organization’s personnel policies and procedures
Establishes schedules of work that ensure productive use of time and meet the requirements for each job function and the needs of the organization and IQS department customers
Reviews and approves all time sheets
Prepares and monitors a budget for the IQS department that encompasses all direct report functions within the department reflecting the mission and goals of the organization
Maintains confidentiality of all activities within the department especially to ensure compliance with California Statute 1157, and will not voluntarily divulge any protected information
Builds and maintains effective working relationships with others
Deals with patients, physicians, employees, and visitors in a friendly and cordial manner, in person or on the telephone, thus promoting a positive service image
Maintains strictest confidence as required under Health Insurance Portability and Accountability (HIPAA) for all patient Protected Health Information (PHI)
All PHI is protected from accidental or intentional, inappropriate disclosure one hundred percent (100%) of the time
Qualification
Required
Bachelor's: Management, public health, nursing, business administration, organizational leadership or related field
12 years recent relevant experience
Leadership and management skills required
Demonstrated leadership skills in a complex environment with the ability to plan, set and accomplish multiple objectives
Proven ability to select, lead, motivate and grow professional staff
Expert skills in verbal and written communication when stakes are high
Ability to work collaboratively with physicians, hospital executives, health plan personnel, governmental personnel, and colleagues in the foundation and Sutter Health
Ability to prioritize, make decisions and set clear expectations for others
Must be computer literate, especially with spreadsheet and word processing software
Must have detailed knowledge of the clinical, business, operational and financial, and regulatory/compliance aspects of commercial and governmental capitated health care programs
Must be well versed in medical foundation and medical group organization and structure
Knowledge of state and federal regulations governing immunity for peer review confidentiality
Working knowledge of Total Quality Management (TQM)/Continuous Quality Improvement (CQI) in clinical settings
Knowledgeable about health care law, regulations, accreditation requirements and clinical standards of practice
Understand business planning including analysis, statistics, budgeting, feasibility studies and implementation
Ability to function independently with minimal management
Understands risk management principles and process
Benefits
Comprehensive benefits package
Company
Sutter Health
Sutter Health is a non-profit organization operating a network of hospitals and physicians in Northern California.
10001+ employees
H1B Sponsorship
Sutter Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (19)
2024 (16)
2023 (14)
2022 (21)
2021 (24)
2020 (30)
Funding
Current Stage
Late StageTotal Funding
$27.17MKey Investors
Department of Health Care Services
2025-05-19Grant· $23M
2016-11-22Grant· $1.2M
2013-10-09Grant· $2M
Leadership Team
Megan Gillespie
Chief Executive Officer
Warner L. Thomas
Chief Executive Officer
Recent News
2025-11-19
2025-11-19
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