A Brief Overview
The Senior Director of Quality Management and Regulatory Affairs is responsible for the strategic planning, oversight and direction of accreditation, regulatory, and licensing across Stanford Health Care. This includes but not limited to continuous readiness plans, peer review process, and care improvement committee responsibilities. Reporting to the Executive Director for Quality, Patient Safety & Infection Prevention, the Senior Director collaborates with cross-functional leaders and teams within Stanford Health Care and Stanford School of Medicine to develop and implement the quality assessment and performance improvement plan (QAPI).

The key areas of responsibility include development and implementation of the strategy and tactics which ensure that the organization is continually prepared for accreditation, federal and state regulatory surveys and compliance with all pertinent regulatory and accreditation requirements.

This is an onsite job that will require traveling to the various locations to round with the operational teams and develop appropriate plans and relationships.

Locations
Stanford Health Care

What you will do

Serve as primary contact for accreditation, certification, and regulatory activities, including survey preparation and readiness assessments for all licensed care areas. Assist with interpretation of standards and regulations and serve as the point of contact for accreditation bodies. Establish and implement organizational regulatory guidelines and planning. Coordinate accreditation activities through the organization, ensure continuous readiness for surveys, and work with senior leadership to target interventions to improve a culture of continuous patient readiness. Responsible for overseeing the organization’s administrative manual and policy and procedure processes. Plan and provide oversight for the peer review staff and management in support of the Chief of Staff and in alignment with medical staff bylaws. Ensure compliance with peer review standards in collaboration with the Chief of Staff and Executive Director for Quality, Patient safety, and Infection Prevention. Provide education for the organization regarding regulatory and accreditation. Identify learning needs and opportunities, and develop/research training content and methods, in collaboration with operational leaders, nursing quality, and medical staff. Responsible for monitoring regulatory websites for new information and new or revised standards, collaboratively evaluating compliance towards those changes. Plan and manage the analysis, summaries, and reports regarding accreditation activities and performance to organizational leadership. Apply project management, people management, and communication skills to lead the continuous readiness plan creation and implementation. Oversee the equitable distribution of accreditation and regulatory team resources, ensuring teams are integrated, visible, and effectively contribute to the organization's strategic objectives. Balance resource allocation to maximize impact and efficiency. Create a working environment that supports the ongoing professional growth and development of all staff, high morale, and optimal job satisfaction. Lead, mentor, coach, and inspire a team of quality professionals through a positive, team-first attitude. Employees must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the health system. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions.

Education Qualifications

Master’s degree in a work-related field/discipline from an accredited college or university required. Master's in Healthcare Quality, Health Policy, Public Health, Health Services Administration, Business Administration or equivalent

Experience Qualifications

Ten (10) plus years of progressively responsible and directly related work experience working with senior executive leadership. Health system operations experience preferred.

Required Knowledge, Skills and Abilities

Demonstration of effective verbal and written communications skills Exceptional leadership, communication, and relationship-building skills, with a strong emphasis on emotional intelligence Demonstrated ability to navigate and influence across all levels of an organization, translating strategic vision into tangible outcomes Ability to interact effectively in a complex organization and in ambiguous situations; ability to manage sensitive situations with exceptional judgment and discretion The successful candidate will produce one or more examples of publication to which she or he has contributed and been recognized as a co-author or acknowledged, or an example of “enduring materials” in other media Knowledge of governmental and other regulatory standards, requirements, and guidelines, specifically, Joint Commission, CMS Conditions of Participation, Title 22, California Business & Professions code, California Health and Safety Code Knowledge of principles and practices of organization, administration, fiscal and personnel management. Knowledge of local, state and federal regulatory requirements related to the functional area. Knowledge of computer systems and software used in functional area, including Electronic Health Records (EHR). . Experience with Microsoft Office Products (including Word, Excel, PowerPoint) and Visio. Experience with tracing/auditing, OPPE/FPPE, Peer review, and policy management electronic systems. Demonstrated ability to manage, organize, prioritize and adapt to changing priorities. Ability to provide leadership and influence others. Ability to foster effective working relationships and build consensus. Ability to mediate and resolve complex problems and issues.

Licenses and Certifications

CPHQ - Health Care Quality Certification preferred . PMP - Project Management Professional preferred . Six Sigma Black Belt Certification (CSSBB) preferred . State board licensure in nursing, social work, physical therapy, respiratory, pharmacy, or profession of relevance preferred .

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family’s perspective:

Know Me: Anticipate my needs and status to deliver effective care Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health Coordinate for Me: Own the complexity of my care through coordination

#LI-RL1

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $94.28 - $124.90 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

Saving Lives and Changing the Future of Medicine

Stanford is a part of the top 10 highest ranked Level 1 Trauma Magnet Facilities in the U.S. Combining clinical care, research, and education, our team provides compassionate, coordinated and personalized care for the unique needs of every patient. As the only Level I trauma center between San Francisco and San Jose, Stanford Health Care delivers clinical innovation across its inpatient services, specialty health centers, physician offices, virtual care offerings and health plan programs. With a state-of-the-art hospital, more than 2,800 medical staff and more than 1,300 residents and fellows, Stanford Health Care is committed to making a lasting impact through research, education and clinical care. 

Benefits

Stanford offers exceptional benefits and competitive pay to ensure our staff feels supported in and outside of their work. Specific roles are eligible for shift differential pay, sign-on/relocation bonus, etc.