Deputy Director-SJGH Nursing – Standards and Compliance
The Position:
San Joaquin County General Hospital is seeking an innovative and knowledgeable Registered Nurse with expertise in specific performance improvement and CQI methodologies, as well as current knowledge of acute and ambulatory care services. This executive at-will position reports directly to Hospital CEO/CNO and is responsible for leading, managing, and administering all program functions of Standards and Compliance department including Infection Control, Quality/Risk Management and Compliance Programs. Additionally, this position will be responsible for Performance Improvement (PI) and Patient Safety plans, accreditations, regulatory survey readiness, and serve as the Hospital’s HIPAA Compliance Officer. The Hospital is seeking a leader who has a high level of integrity, possesses strong ethics, and who has a proven track record of developing and maintaining high standards of quality.
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Typical Duties:
Responsible for the design, coordination, and management of the Performance Improvement (PI) and Patient Safety Plans and ensures their effectiveness is evaluated annually.
Identifies opportunities for improved patient care, outcomes, and reduction in harm with the implementation of evidence-based practices.
Establishes performance improvement goals annually with key stakeholders.
Develops/implements processes which support data collection, aggregation, analysis, action planning, and the dissemination of data to appropriate leadership staff.
Provides leadership in developing quality improvement and patient safety training programs and coaches departments in quality improvement principles.
Oversees the event reporting process, root cause analyses, investigation, and requests for claims team (including subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability).
Responsible for accreditations and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness.
Is the HIPAA compliance officer who investigates potential breaches in protected information and notifies both the patients and regulatory agencies. Establishes plans and communication to minimize the organization risks associated with HIPAA violations.
Compensation and Benefits:
A 2% employer contribution to the County’s 457 Deferred Compensation Plan
Vacation cash-out up to 8 days annually
937 Retirement Act plan — reciprocity with CALPERS
125 Flex Benefits Plan
12 days sick leave annually — unlimited accumulation
15 days of vacation leave (20 days after 10 years and 23 days after 20 years)
14 paid holidays per year
10 days administrative leave per year
Up to $5,000 of reimbursement for documented cost of moving
Vacation Accrual Rate consistent with candidate’s total years of public service.
Credit of candidate’s actual reimbursable sick leave hours from candidate’s last agency up to 160 hours.
Desired Qualifications:
*Highly Qualified Candidates will possess a combination of:
Education: A Bachelor’s Degree in Nursing, Health Care Administration or Business Administration or other closely related field. Completion of a Master’s Degree in Nursing or Business Administration is preferred.
Experience: Four years progressively responsible experience as a registered nurse in an acute care hospital of 100 or more beds, including one year of management experience at a level equal to Nursing Department Manager.
REQUIRED Qualifications:
License: Current registration as a Nurse in the State of California is required
Certification: Candidate must be a Certified Professional in Healthcare Quality (CPHQ), or possess a Healthcare Quality and Management Certification (HCQM) or Certification of Professional Healthcare Quality and Safety (CPQPS).
All interested candidates are encouraged to apply.