POSITION SUMMARY

The Director, Quality & Patient Safety provides strategic and operational leadership for quality management, patient safety, and performance improvement activities. This position is responsible for the design, implementation, evaluation, and continuous improvement of programs that support clinical excellence, patient safety, and optimal patient outcomes. The Director oversees the Patient Safety Program, and Performance Improvement Plan, ensuring alignment with organizational goals and compliance with requirements established by The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, and other applicable standards. The Director serves as a key leader in quality and safety initiatives, collaborates closely with executive leadership, medical staff, and department leaders, and provides consultation, education, and performance improvement expertise throughout the organization.

QUALIFICATIONS EDUCATION

Bachelor's degree in nursing or related healthcare field required. Master's degree in health care administration, Business Administration or healthcare related field preferred.

LICENSE/CERTIFICATION

Additional certifications in Patient Safety, Healthcare Quality, Regulatory Compliance, or Healthcare Leadership preferred.

EXPERIENCE

Minimum 3-5 years of progressive leadership experience in quality management, patient safety, or related healthcare functions preferred. Experience with data analysis, performance measurement, and quality improvement methodologies. Demonstrated expertise in Patient Safety. Excellent verbal & written communication skills required. Excellent Leadership skills required.

PERFORMANCE EXPECTATIONS

Demonstrates the clinical competencies as established on the Assessment and Evaluation Tool.

WORK ENVIRONMENT

Potential for exposure to the hazards and risk of the hospital environment, including exposure to infectious disease, hazardous substances, and potential injury. Requires the ability to walk, stand and reach a majority of the time. Intact vision and speech as well as sufficient hearing is also required. The essential functions for this position are listed on the Assessment and Evaluation Tool. Core Competencies will be assessed primarily on the following patient population(s) served: Quality Management and Performance Improvement, Patient Safety Leadership, Clinical Outcomes Improvement

REPORTING RELATIONSHIP

This position reports to the Assistant Vice President of Quality and Accreditation and supervises incumbents as assigned. The above statement reflects the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.

EDUCATION

Bachelor's degree in nursing or related healthcare field required. Master's degree in health care administration, Business Administration or healthcare related field preferred.

LICENSE/CERTIFICATION

: Additional certifications in Patient Safety, Healthcare Quality, Regulatory Compliance, or Healthcare Leadership preferred.

EXPERIENCE

Minimum 3-5 years of progressive leadership experience in quality management, patient safety, or related healthcare functions preferred . Experience with data analysis, performance measurement, and quality improvement methodologies . Demonstrated expertise in Patient Safety. Excellent verbal & written communication skills required. Excellent Leadership skills required.