Area Safety & Quality Officer

Area Safety & Quality Officer

Location: Modesto, CA
Employment Type: Permanent
Job Level: Director/Senior Director
Travel: Approximately 20%
Salary: $216,700 – $255,000 per year
Work Arrangement: 100% onsite for rounding responsibilities
Service Area: Responsible for supporting two hospitals within the assigned service area
 

About the Organization

The organization is a large, multifaceted healthcare system committed to delivering high-quality, safe, and patient-centered care across multiple facilities and service areas. It places a strong emphasis on clinical quality, patient safety, regulatory compliance, infection prevention, risk management, and continuous improvement.

The organization works closely with healthcare professionals, executive leadership, clinical teams, and cross-functional stakeholders to improve patient outcomes, strengthen quality programs, and maintain compliance with applicable healthcare standards and regulations.

Position Overview

The Area Safety & Quality Officer will provide strategic oversight and guidance for small- and medium-sized healthcare service areas, including facilities with fewer than 300 licensed beds.

This position will be responsible for leading the development and implementation of clinical quality, patient safety, risk management, infection prevention, and performance improvement programs. The role will serve as a senior subject matter expert and strategic partner to executive leadership, medical staff, clinical teams, and other stakeholders.

The position will proactively monitor performance metrics and improvement activities, promote evidence-based practices, oversee accreditation and regulatory activities, and help develop systems designed to reduce care delivery risks and medical errors.

The position will be responsible for supporting two hospitals within the assigned service area and will be onsite 100% of the time for rounding.

Essential Responsibilities

Leadership & Organizational Development

• Build organizational capacity and prepare high-potential employees for growth opportunities and advancement.
• Develop collaborative networks inside and outside the organization for self and others.
• Establish frameworks for soliciting and acting on performance feedback.
• Drive collaboration to establish goals and provide open feedback and coaching to support performance improvement.
• Promote continuous learning and oversee the recruitment, selection, and development of talent.
• Remain current with industry trends, benchmarks, and best practices and share those practices across teams.
• Motivate and empower teams while maintaining a highly skilled and engaged workforce.
• Align cross-functional resource plans with business objectives.
• Provide guidance in complex decision-making situations and create opportunities for expanded decision-making responsibilities across teams.

Operational & Strategic Oversight

• Oversee the operations of multiple units and/or departments by identifying member and operational needs.
• Ensure appropriate allocation and completion of work assignments.
• Translate business strategy into actionable business requirements.
• Ensure products and services meet member requirements and expectations while aligning with organizational strategies.
• Engage strategic and cross-functional business units to support business plans and priorities.
• Establish standards, measure progress, and ensure resolution of escalated issues.
• Set and communicate goals and objectives.
• Analyze resources, costs, and forecasts and incorporate them into business plans.
• Obtain and distribute resources effectively.
• Anticipate and remove obstacles affecting performance.
• Address performance gaps and implement contingency plans as needed.
• Serve as a subject matter expert and trusted resource to executive leadership.
• Provide influence and consultation in the development of broader organizational and business strategies.

Clinical Quality & Regulatory Compliance

• Serve as a subject matter expert for clinical quality improvement processes and healthcare regulations.
• Provide consultation regarding the interpretation, interaction, and implementation of current policies, regulations, and legislation.
• Advise leadership on long-term strategies related to regulatory requirements and changes that may affect business operations.
• Engage internal and external committees, projects, and quality initiatives to drive organizational change.
• Identify infrastructure and process changes necessary to advance quality initiatives and maintain compliance.
• Foster collaborative, results-oriented partnerships with practitioners, staff, management, and clinical and administrative departments.
• Influence the development and direction of policies and strategies to support regulatory compliance.
• Help determine future educational programs related to regulatory requirements, internal concerns, and system/database usage.
• Identify and remove barriers to process improvement while considering practical, technical, and organizational capabilities.
• Advise on policy changes and quality improvement strategies.

Quality of Care Complaints & Review

• Oversee the outcomes of quality-of-care complaint and review processes.
• Represent the organization in grievance meetings, cases, reviews, referrals, and other applicable mechanisms.
• Direct the preparation of documentation, records, and information requested for sensitive patient case reviews.
• Analyze trends in investigations and claims, including red flags, appeal reasons, and overturns.
• Report findings and provide strategic recommendations to reduce recurrence.
• Establish standards for surveillance of quality improvement metrics, quality-of-care incidents, cases, and near misses.
• Ensure consistent application of established quality policies and protocols.

Infection Prevention & Control

• Oversee infection prevention and control programs designed to improve employee and patient safety.
• Present information from epidemiological investigations, simulations, and research involving significant infection clusters or serious communicable disease concerns.
• Support prevention, surveillance, and outbreak management strategies.
• Serve as a primary contact during significant outbreak containment efforts.
• Consult with administration regarding infection control considerations related to architectural design, renovation, and construction projects.

Risk Management

• Direct risk management activities across the assigned service area.
• Define and present standards for corrective action plans resulting from utilization reviews, clinical record audits, claim denials, patient satisfaction surveys, and audit findings.
• Utilize root cause analysis, failure mode and effects analysis, and other assessment methodologies following significant events, near misses, and identified concerns.
• Develop policies and procedures designed to mitigate future risks.
• Establish standards for health outcome analysis and ongoing monitoring of oversight effectiveness.

Patient Safety

• Oversee patient safety programs and initiatives.
• Serve as a primary contact during significant event management and responses involving safety hazards, accidents, incidents, threats, and other significant events.
• Collaborate with executive management and external stakeholders to develop patient care and satisfaction programs.
• Support initiatives designed to improve patient flow, clinical support, patient services, and seamless transitions of care.

Clinical Quality Improvement Programs

• Oversee the development of new clinical quality improvement programs.
• Maintain relationships with key stakeholders, senior management, and external stakeholders.
• Influence long-term strategic planning related to quality guidelines, metrics, and operational definitions.
• Ensure sustainability of quality improvement programs.
• Serve as a subject matter expert regarding healthcare concepts, regulatory requirements, and change management principles.
• Ensure organizational strategies prioritize initiatives that optimize clinical quality, patient safety, and health outcomes.
• Provide strategic insight into opportunities for organizational learning and improvement.
• Advocate for quality programs and consult with executive management, technology stakeholders, and external vendors.

Data Management & Performance Improvement

• Oversee systems, procedures, and forms designed to improve data management programs.
• Utilize data to monitor and improve employee and patient safety programs.
• Ensure quality improvement monitoring includes appropriate data management and analysis.
• Integrate trends and patterns of practice into long-term strategic planning.
• Interpret and apply data from databases, vital statistics, hospital patient discharge data, claims, and other relevant healthcare sources.
• Provide data-driven recommendations to support long-term organizational strategy.
• Present reports and analysis related to infection control research, utilization reviews, population health needs, patient satisfaction, and other quality measures to executive stakeholders.

Regulatory Audits & Survey Readiness

• Oversee regulatory audits and survey activities.
• Serve as the primary contact between applicable government and regulatory organizations and management during onsite visits and evaluations.
• Establish standards for audit documentation, requested information, reports, and supporting tools.
• Maintain appropriate documentation and reporting standards throughout the audit process.
• Forecast regulatory changes and establish continuous survey-readiness activities.

Medical Care & Utilization Oversight

• Define the future direction and standards for evaluating the cost-effectiveness, practicality, and appropriateness of medical care.
• Ensure case reviews are completed and appropriate follow-up is conducted.
• Partner with key stakeholders to support practitioners and departments in following standard operating procedures for treatment and applicable medical codes.
• Advocate for resolution of systemic concerns to ensure patient treatment plans meet patient needs in a timely manner.
• Establish standards related to population health needs and use findings to guide policy and strategic direction.
• Address community health concerns, access to transportation, patient rights, appointment no-shows, and other relevant population health considerations.
• Use findings from previous patient case reviews to advocate for policy and technology improvements.

Qualifications

Minimum Qualifications

• Minimum 10 years of experience in clinical and management roles within a health plan or multifaceted healthcare system and multi-provider environment.
• Master’s degree in Business, Healthcare, Public Administration, or a directly related field, and a minimum of 7 years of healthcare experience or experience in a directly related field.
• Minimum 4 years of experience managing operational or project budgets.
• Minimum 9 years of experience in a leadership role, with or without direct reports.
• Minimum 6 years of experience working with databases and spreadsheets.
• Minimum 4 years of experience delivering training programs.
• Minimum 8 years of experience in a clinical setting, healthcare administration, or a directly related field.

Certification

• Professional Healthcare Quality Certification must be obtained within 24 months of hire.