Director of Quality and Risk

Chinese Hospital

845 Jackson St, San Francisco, CA 94133

About this role

Department: Quality and Risk
Report to: VP Quality, Risk, Compliance Medical Staff
Type: Full-time
Requisition #10248

Position Summary

The Director of Quality and Risk provides leadership, management and administrative oversite of the development and implementation of the hospitals quality, patient which includes internal, external, licensing departments and risk management. The Director will develop metrics in quality and patient safety, ensure all policies and procedures are in compliance and act as an expert resource for all hospital departments

Essential Duties and Responsibilities

  • Ensure the organization maintains appropriate IT Security, administrative, technical, and physical safeguards to protect health information and work in collaboration with the Chief Information Security Officer or designee.
  • Engage leadership team, employees, and volunteers in a Culture of Safety.
  • Work with management in the development and implementation of appropriate internal controls and measurements to reasonably ensure that the activities of the organization comply with the law, regulation, and rules.
  • Evaluate the organization for potential risks, opportunities for improvement, and propose solutions for minimizing and mitigating the risks.
  • Manage the incident reporting process (e.g. grievances, adverse events, and violations) and develop a records management system for the risk management program that is secure, accurate, complete, and evaluated regularly for destruction or retention.
  • Promptly inform the Administrator and Chief Nursing Operations Officer (CNO) and appropriate department heads regarding any identified organizational risk and discuss recommendations for mitigating the risk.
  • Prepare dashboard and analysis of reported incidents with solutions/proposed solutions.
  • Investigate and respond to patients/residents/representatives with grievances and concerns
  • In conjunction with the CNO and Administrator, performs complex Root Cause Analysis (RCA) investigations and consults with legal counsel, the Board, the VP of Operations, and/or the Chief Executive Officer, to determine the appropriate response of the organization to detected violations and opportunities for improvement.
  • Develop, implement, communicate and maintain a quality plan to ensure the Hospital is in compliance with regulatory requirements.
  • Develop internal measures such as peer review to ensure the safety and quality of care provided by the Hospital to patients.
  • Lead site effort to implement and train leadership, departmental managers, and staff to ensure site is compliant with all state and federal regulations.
  • Plans and conducts internal monitoring to ensure the organization is compliance with regulatory requirements.
  • Observe and evaluate processes to make appropriate decisions on issues relating to quality program adherence and improvement.
  • Coordinate and manage the activities and investigations of patient care
  • Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct.
  • Manages day-to-day operation of the Program.
  • Works with CHA General Counsel to periodically review and updates Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
  • Collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with CHA General Counsel as needed to resolve difficult legal compliance issues.
  • Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures.
  • Develops and oversees a system for uniform handling of such violations.
  • Acts as an independent review and evaluation body to ensure that compliance issues/concerns within the organization are being appropriately evaluated, investigated and resolved.
  • Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
  • Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.
  • Provides reports on a regular basis, and as directed or requested, to keep the Corporate Compliance Committee of the Board and senior management informed of the operation and progress of compliance efforts.
  • Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
  • Establishes and provides direction and management of the compliance Hotline.
  • Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.
  • Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.
  • Monitors the performance of the Compliance Program and relates activities on a continuing basis, taking appropriate steps to improve its effectiveness.
  • Follows Hospital and Department policies and procedures at all times, including but not limited to: Administrative Manual, Environment of Care, Human Resources, Infection Control, Corporate Compliance, Code of Ethics, etc.
  • Customer Service – Provides excellent customer service and shows compassion to all patients, visitors and co-workers.  Seeks feedback to ensure all needs are met. Anticipates and recognizes the concerns of others, even if those concerns are not openly expressed.
  • Accepts and performs other duties as assigned.


  • CA Licensed Registered Nurse
  • Three to five years of experience in ongoing monitoring techniques in quality management and regulatory surveys
  • Knowledgeable with TJC/DHS/CMS regulatory standards as well as TJC disease- specific care certification process
  • Demonstrated experience working with physicians, physician leaders, and Administrative leadership
  • Well-developed organizational, communication and analytical skills.
  • The ability to critically evaluate and troubleshoot patient care concerns is essential.
  • Experience in LEAN and six sigma preferred.
  • Excellent computer skills, exposure to managing people and projects, and the ability to handle multiple tasks.
  • Certification in Healthcare Privacy and Corporate Compliance (CHPC) preferred in ideal candidates. Education: A Bachelor’s degree required; Master’s Degree in health care administration, nursing, business and JD preferred.  Course in medical staff office functions.
  • Experience: A minimum of 10 years’ experience in a hospital or healthcare organization, to include demonstrated leadership. Familiarity with hospital or healthcare operational, financial, quality assurance, and compliance regulations required. Clinical nursing and hospital experience preferred.
  • Organizational, managerial, problem-solving skills; communication skills; ability to work independently and to assume responsibility;
  • Knowledge of current accreditation standards, state and legal requirements pertaining to the medical staff
  • Computer proficiency (Microsoft Office) (EMR knowledge a plus)
  • Strong communication skills.
  • Ability to effectively present information, both verbal and written.

Physical Requirements

While performing the duties of this job, staff is regularly required to sit, stand, walk, talk and/or listen. He/she uses his/her hands to do computer work, write reports, do equipment set-up/cleaning/storage, clerical support, etc. He/she will be using the phone frequently. Good vision is needed to be able to read schedules, enter accurate data, etc. He/she must have good general health and demonstrate emotional stability so as to carry out the above-enumerated duties.

  • Able to lift up to 30 pounds
  • Use proper body mechanics when handling equipment
  • Standing, walking and moving 50% of the day

Compliance Requirements

Complies with Chinese Hospital Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.


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