Senior Director of Quality, Patient Safety, and Professional Excellence

Description

Experience                                                                                  

This senior executive position requires a minimum of 10 years of progressive healthcare leadership experience. This must include at least 3 to 5 years in a senior leadership role (e.g., Senior Director or Director) within an acute care hospital, with a preference for experience in an Essential Hospital or a similar complex healthcare setting.

The ideal candidate will have a proven track record in the design, development, and implementation of Quality, Incident Management, and Patient Safety programs. They must demonstrate success in improving clinical quality and patient experience outcomes by utilizing Lean Six Sigma and High Reliability Organization (HRO) principles.

Core Competencies

• Visionary Leadership: Ability to inspire and lead clinical and quality teams toward a shared vision of Clinical Excellence and zero-harm patient safety.
• Regulatory & Quality Expertise: Deep knowledge of Joint Commission, CMS, CDC, and Leapfrog standards, with a demonstrated proficiency in navigating assessment and survey processes to achieve sustainable outcomes.
• Operational & Improvement Science: High degree of knowledge in Lean Six Sigma, Project Management, and Change Management to drive performance improvement across diverse hospital units. 
• Analytical Acumen: Ability to link clinical data analysis to hospital goals, including financial performance, patient satisfaction, and care delivery outcomes.
• Collaborative Advocacy: A natural ability to build trusting relationships with physicians and staff while serving as the primary liaison for hospital accreditation and the Patient Safety Officer. 
• Technical Integrity: A leader capable of conducting rigorous event investigations (RCA) and risk analyses (FMEA) with unquestionable professional integrity and a commitment to transparency.

Primary Duties and Responsibilities:

Patient Safety & High-Reliability Operations 

• Oversee hospital-wide patient safety programs, including:

• Event reporting systems
• Root Cause Analyses (RCA)
• Failure Mode and Effects Analysis (FMEA)
• Serious safety event management
• Promote Just Culture principles and psychological safety for staff.
• Efforts to reduce hospital-acquired conditions (HACs), preventable readmissions, and adverse events.
• Ensure timely follow-up, corrective action planning, and sustainability of safety improvements

 Quality, Safety & Regulatory Readiness:

• Implement, maintain, and evaluate a comprehensive Quality and Patient Safety program that oversees care delivery performance and outcomes.
• Serve as the primary point of contact for The Joint Commission, CMS, CDC, and Leapfrog; coordinate all accreditation standards, surveys, and reporting.
• Lead clinical risk management investigations, incident report analysis, and serve as a lead investigator for Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
• Oversee the integration of infection prevention and contamination control principles across all hospital units.

Clinical Excellence & Professional Development:

• Direct an integrated program for clinical excellence, incorporating Lean Six Sigma, Change Management, and Project Management methodologies into staff development.
• Provide educational support for Providers to support medical staff competency and high-quality care.
• Transfer and implement High Reliability Organization (HRO) principles, behaviors, and tools across the organization to foster a culture of safety and excellence.
• Link clinical outcomes and patient satisfaction data to targeted professional development initiatives to address identified performance gaps.Data Analysis and Reporting

• Oversee the collection, validation, analysis, and interpretation of quality and patient safety data.
• Identify trends, disparities, and opportunities for improvement.
• Present quality and safety performance reports to executive leadership, medical staff committees, and the Board of Trustees.

Certification / Licensure: 

Required: Must hold or obtain two of the following within 12 months of hire:CPHQ, CPSO, CQMS, or CLSSB. 

Required: Master’s degree in Nursing (MSN), Healthcare Administration (MHA), Business Administration (MBA), Quality and Safety (MHA) or a related field

Preferred:Candidates with an active Nursing or clinical license will be given special consideration.

Additional Education Preferred: Doctorate in Nursing Practice (DNP), Doctor of Healthcare Administration (DHA), or related field (Ph.D.).

We are an E-Verify employer.

For more information, please click on the following links:
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