Position Description: Director, Licensure and Accreditation, Kaiser Permanente, Kaiser Hospital

The Opportunity

Kaiser Permanente, America's leading nonprofit integrated health plans, is opening a new 224-bed hospital in Modesto, California in 2007/2008.  This opportunity will provide the successful candidate an opportunity to participate in the competition of the facility, staffing, developing, introducing and managing the Quality Assurance function at the hospital.  A seasoned professional will have the responsibility of building “their own” quality department from the ground up.

As an employer, Kaiser Permanente recently ranked 11th in the large employer category among the 100 Best Places to Work in the Bay Area by the San Francisco Business Times, Silicon Valley/San Jose Business Journal, and the East Bay Business Times. In 2005, DiversityInc magazine recognized Kaiser Permanente as one of its 25 Notable Companies for Diversity.

Our Client

Kaiser Permanente serves approximately 8.2 million people in nine states and the District of Columbia.
Kaiser Permanente Northern California and Kaiser Permanente Southern California received the highest overall ratings for clinical quality among all health plans in California on the California Cooperative Healthcare Reporting Initiative (CCHRI) Report on Quality, 2005.  Kaiser Permanente earned more three-star or excellent ratings than any other health plan surveyed in a 2005 report card from the California Office of the Patient Advocate.  

In September, 2005, readers of America's leading consumer magazine gave Kaiser Permanente high marks for customer satisfaction.  An October 31, 2004, article in The New York Times featured Kaiser Permanente, with the headline, "Is Kaiser the Future of American Health Care?"  According to the article, economists and medical experts say "Kaiser is a leader in the drive both to increase the quality of care and to spend health dollars more wisely, using technology and incentives tailored to those goals."

Kaiser Permanente of California earned "Excellent" ratings from the National Committee for Quality Assurance (NCQA), the Nation's leading independent reviewer of health plan quality for consumers and employers.  "Excellent" is the top rating granted by NCQA, based on service and access to care, preventive measures, physician credentialing, how well members recover from illness, and how well they live with chronic conditions.

Management

An overview of top management of the hospital shows an exceptional blend of clinical, operational and business expertise in the field of acute and specialty care and services.  Underlying the management team's skill-set is a passionate, deep-seeded and visionary commitment to clinical excellence, innovation and growth.  The style of management and the organizational culture of excellence are deeply rooted in teamwork and mutual support. 

This group of Managers and Directors, with their collaborative style and complete commitment to the mission, is the heart of the quality performance program.  It is readily apparent that the management team consistently emphasizes teamwork, individual achievement and making the job fun.

To complement the management team, an individual must be able to blend their individual success into that of the entire team and share in the commitment and the satisfaction of taking care of the healthcare needs of the community.

Reporting Relationship and Departmental Overview

Position reports the Assistant Administrator, Quality and Service.  The Director, Quality and Service will have one/two Advanced Nurse Practitioners and two/three Analysts (Project Management) directly reporting to this position.  The growth of the department as the hospital opens and expands will determine the numbers of reports as found in the above.  There is a pool of Data Analysts that serve the department. 

The Assistant Administrator, Quality and Service reports directly to the Senior Vice President of the Service Area.

The Assistant Administrator, Quality and Service, who this position reports to, has been with Kaiser Permanente for 25 years.  She has served as an executive in the Kaiser Permanente Northern California Region and at a national level where she was the Corporate Director, Quality and Service.

Position Description

The Director, Quality and Service directs the Medical Center's operations and activities to comply with all accreditation, regulation, and licensing requirements for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan. 

The Director, Quality and Service translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses.  He/she implements systems to effectively monitor compliance to standards and to implement new processes to meet new requirements.

The Director, Quality and Service is responsible for guiding, building and leading the hospital’s Clinical Quality and Performance Improvement (PI) program to support the Hospital's mission, values and business objectives.  Key focuses for this position include:

The position plans, organizes and directs all aspects of the Clinical Quality functions including clinical outcomes, patient safety, environment of care safety, infection control, risk management, operational improvements, service quality and organizational regulatory and accreditation readiness.  The Director, in collaboration with other members of the department, provides the organization with focus and education on performance improvement, outcomes reporting, and regulatory issues. 

Responsibilities

• Directs the Medical Center's operations and activities to comply with all licensing and accreditation standards and requirements, ensuring consistency with organizational goals and priorities. 
• Works closely with designated Chiefs of Service and Department Managers to ensure that principles of confidentiality and responsibility are adhered to.  
• Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals.  
• Provides education and technical support to the Medical Center in developing, implementing and maintaining regulatory compliance. 
• Partners with Risk Management to reduce medical/legal liability through development of a program which links risk management activities with those of regulatory compliance. 
• Serves as a critical link in the identification and resolution of issues, which affect organizational image. 
• Develops and maintains relationships and effective communication with all levels of the Medical Center’s physicians and staff in order to facilitate problem identification and resolution. 
• Manages staff and makes recommendations regarding the need for staff, space and other resources. 
• Manages and resolves human resources and labor relations issues specific to management responsibilities. 
• Develops systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery.
• Analyzes, interprets and makes recommendations to meet federal, state and local requirements. 
• Identifies key accreditation, regulation and licensing issues and defines areas for improvement.  
• Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective action to minimize negative impact and maximize learning.
• Relays internal/external communication of information related to accreditation, regulation and licensing. 
• Partners with the Assistant Administrator to prepare for surveys and inspections, including educational forums, coordinating mock surveys and assessments assists in developing response plans. 
• Coordinates formal surveys for all regulatory and accrediting agencies.
• Interprets and assists in planning responses to new or changing regulations or standards. 
• Collaborates with external regulators to develop standards that promote high quality patient care and services. 
• Serves as liaison to region, community groups, professional organizations, and licensing/regulatory agencies. 
• Develops, implements, and meets the established financial goals.  Monitors applicable budget; and identifies and supports solutions to reduce cost structure.  
• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures.

Education 

Bachelor’s Degree in Healthcare Administration, Nursing, or Public Administration or related field required.  Other clinical licensure or Master's Degree in related field required. 

Certification/License 

Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred.

Qualifications

• Experience designing, developing, implementing clinical improvement programs. 
• Significant experience (usually 5 years) in Quality Improvement in a healthcare setting.
• Previous management experience required. 
• Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement, such as JCAHO, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22, Cal-OSHA, HIPAA  and Medi-Cal and Medicare regulations and standards. 
• Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques.
• Effective communication, negotiation and leadership skills.  Must be able to work in a Labor/Management Partnership environment.

Personal Characteristics

Director, Quality and Service needs to possess the patience, self-confidence and communication skills necessary to work with clinical and administrative staff and the Physicians.

First and foremost, this individual needs to be a team player, be a superb communicator and have the style of a diplomat, i.e., be able to work in harmony with other operational entities and to negotiate agreements so each party benefits. It is imperative that he/she be skilled in bringing together the staff functions in a spirit of harmony and with a single-minded purpose.

A hands-on leader who can develop a strategic vision of the department and has the expertise to develop values and goals for a diverse group of constituents will be successful.  The successful candidate will have a proven record of accomplishment and strong leadership skills to ensure that the improvement process within the department continues and priorities are established and the goals are met.

The successful candidate will be a person who possesses a strong work ethic, rejects setbacks and values accomplishments highly.  An action-oriented personality that deals with specifics within a broad conceptual framework will be most effective in this position.  This individual will have an appropriate sense of urgency to react to situations quickly and decisively.

Compensation

Kaiser Permanente is committed to providing its employees with a highly competitive Total Compensation Program.  Kaiser approaches pay and benefits as a "total compensation" package which includes wage programs, pay practices, paid time off and benefits.  This comprehensive program includes the Benefits by Design flexible benefits program. Also, Kaiser Permanente provides a Paid Time Off (PTO) Program, Retirement Plans, as well as other benefits.

About Modesto (Stanislaus County)

Modesto is well known for its warm, friendly people who give Modesto a hometown feel, with the amenities and attractions of a big city.

Modesto’s central location puts you within a short drive of the ocean, mountains and some of the nation’s most renowned parks. Day trip options from Modesto include San Francisco, Sacramento, Lake Tahoe (snow skiing, summer sports, plus), the Delta (river rafting, hiking, or jet skiing), and Yosemite National Park among many others.

The mild climate makes outdoor activities enjoyable year round. Modesto is in the heart of one of the greatest agricultural areas in our nation, the fertile San Joaquin Valley. Dairy products, nuts, fruits, wine grapes, and poultry products are some of its top commodities. In early spring, the beautiful orchards in bloom will delight you. May through November is harvest season. You can “taste Modesto” at Farmers Markets and the many fresh produce stands in the area.

The housing costs in the area are affordable and contemporary.  You simply can’t go wrong in Modesto.  It has something for everyone.

To further inquire about his opportunity please contact:

Robert E. Reilly
Reilly & Associates
80 North Cabrillo Highway, Suite Q #204
Half Moon Bay, CA  94019
Phone: (650) 726-2199
Fax: (650) 712-8028
bob@reilly-search.com
www.reilly-search.com

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