"Senior Director of Quality and Patient Safety"

Under the general direction of the Vice President for Quality and Patient Safety, the Senior Director for Quality & Patient Safety, Saint Francis (SF) and St. Mary's (SM). provides strategic direction, executive level leadership, planning, organization and general management for all aspects of the SF's and SM's Quality & Patient Safety program. This highly visible and matrixed senior leadership role will partner with the SF and SM executive team, the UCSF Health Quality and Patient Safety executive team and other key partners (e.g. physician leaders, UCSF Health leaders, affiliates/partners, etc.) to develop and execute a strategy for Quality and Patient Safety across the SF and SM enterprise. The incumbent is responsible for meeting or exceeding the institutional goals set for Quality & Patient Safety across SF and SM and to external reporting bodies.

Specific areas of responsibility include the following:

• SF and SM Quality Improvement (across spectrum of care at UCSF Health Community Hospitals)
• Patient Safety
• Regulatory Compliance, in partnership with UCSF Health Director of Regulatory Affairs
• Hospital Epidemiology & Infection Control (HEIC),
• Data Analytics
• Patient Experience, in partnership with UCSF Health Division Director of Experience
• Quality and Regulatory for 20 outpatient departments:
  • MACRA/MIPS quality measure & submission
  • CLIA licenses
  • SF city business licenses
• Outpatient Prospective Payment System (OPPS) management
• RAC audits (Reduction Recovery Audits)
• On-site Payor audits for clinics (i.e. BCBS)
• CMS STARs rating review & analysis, and action planning
• Accreditation programs/surveys not covered by Regulatory:

• CEEP School (Counseling Enriched Education Program)
  • San Francisco Department of Public Health Community Behavioral Health Services annual program audit
• College of American Pathologists/ Laboratory (CAP)
• Surgical Review Corporation for Transgender Program
• American Burn Association Burn Center Verification ICU Burn Unit
• San Francisco Department of Public: Business Office of Contract Compliance for Integrated HIV Services Review
• California Department of Public Health Infectious Disease Bureau
• Diabetes Self-Mgmt Training (DSMT) entity Audit (CMS via IMS)
• Commission on Accreditation of Rehabilitation Facilities (CARF)
• Inpatient Diabetic Nurse Educator (review hypoglycemia episodes, diabetic champions, etc)
• Orthopedic Service Line
  • IPPS
  • CMS Core Measures
• Leapfrog Survey

The final salary and offer components are subject to additional approvals based on UC policy. Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.

The salary range for this position is $144,200 - $350,000 (Annual Rate).

To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html