Director of Quality & Patient Safety

Supports ongoing compliance with The Joint Commission, CMS Conditions of Participation, NJDOH, and other accreditation and licensing requirements through tracer activities, mock surveys, rounding, performance improvement initiatives, and continuous readiness efforts. Provides oversight of the Quality/Regulatory team, Infection Prevention Program, Patient Experience Program, and quality data systems, including management and reporting of key clinical, regulatory, patient safety, and performance improvement metrics.

Overview:

Join our team as a day-shift, full-time, Quality & Patient Safety Director of Quality in Westwood, NJ. 

 

Why Join Us? 

 

Thrive in a People-First Environment and Make Healthcare Better 

• Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. 
• People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. 
• Make Healthcare Better: We use advanced technology to support our team and enhance patient care. 
• Learn more about the benefits offered for this job. 

Get to Know Your Team: 

• Hackensack Meridian Pascack Valley Medical Center is a 128-bed, full-service, acute-care community hospital with a new emergency department, a state-of-the-art maternity center, a women's imaging center, and an ICU.

Responsibilities:

• Leads and integrates a comprehensive Quality Assessment and Performance Improvement (QAPI) program focused on quality outcomes, patient safety, regulatory compliance, operational excellence, and High Reliability Organization (HRO) principles.
• Responsible for hospital-wide performance improvement initiatives and publicly reported quality programs, including CMS Core Measures, Value-Based Programs, Leapfrog, NDNQI, and Joint Commission (TJC) standards. Oversees quality metrics, data analysis, benchmarking, corrective action plans, and regulatory reporting.
• Partners with the CQO, administration, nursing leadership, medical staff, and department leaders to drive patient safety, quality improvement, accreditation readiness, survey readiness, and regulatory compliance across the organization.
• Supports ongoing compliance with The Joint Commission, CMS Conditions of Participation, NJDOH, and other accreditation and licensing requirements through tracer activities, mock surveys, rounding, performance improvement initiatives, and continuous readiness efforts.
• Collaborates closely with Risk Management, Compliance, Patient Safety, and Infection Prevention leadership to advance a culture of safety, reduce risk, improve outcomes, and ensure regulatory excellence.
• Provides oversight of the Quality/Regulatory team, Infection Prevention Program, Patient Experience Program, and quality data systems, including management and reporting of key clinical, regulatory, patient safety, and performance improvement metrics.

Qualifications:

Job Requirements: 

• Bachelor’s Degree in Nursing.
• 5-7 years’ experience with quality management, data collection and reporting methodology, and/or clinical chart review and abstraction experience. 
• Registered Nurse with a minimum of 5 years of clinical background in a hospital setting. 
• Proficient with Microsoft Word, Excel, and PowerPoint.
• Database data entry and/or management experience.
• Knowledge of clinical quality data and outcomes.

Preferred Job Qualifications:  

• Master’s Degree.
• 2-3 years of leadership experience.
• CPHQ.

 

Rate of pay is determined based on experience and education, and may include other pay components such as differentials and call pay based on role.  

 

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